Service Recipient Record Requirements

(1) The individual service recipient record must include the following: (a) Documented findings of an assessment using a standardized nationally recognized assessment instrument approved by the Tennessee Department of Mental Health and Substance Abuse Services Division of Alcohol and Drug Abuse Services; and (b) Referral to an appropriate treatment resource and notification of such referral to the initial referral source, if the service recipient assessment indicates an alcohol and drug problem. The facility must document referral services recommended and/or required for the service recipient, if applicable.