Service Recipient Record Requirements

(1) The individual service recipient record must include the following: (a) Documentation on a medications log sheet of all medications prescribed or administered with the date of the prescription, date of administration, type, dosage, frequency, amount, and reason; (b) Documentation of the service recipient’s employment related problem or problems and goal or goals on the IPP, and the service recipient’s progress or lack of progress towards meeting the goal or goals in the progress notes, or clinical justification for an exception to the policy and procedure; (c) A list of each individual article of each service recipient’s personal property valued at one hundred dollars ($100.00) or more including its disposition, if no longer in use; (d) Written accounts of all monies received and disbursed on behalf of the service recipient; (e) Reports of medical problems, accidents, seizures, and illnesses and treatments for such accidents, seizures, and illnesses; (f) Reports of significant behavior incidents; (g) Reports of any instance of physical holding or restriction with documented justification and authorization; (h) A discharge summary which states the date of discharge, reasons for discharge, and referral for other services, if appropriate; and (i) An aftercare plan which specifies the type of contact, planned frequency of contact, and responsible staff; or documentation that the service recipient was offered aftercare but decided not to participate; or documentation that the service recipient dropped out of treatment and is therefore not available for aftercare planning; or verification that the service recipient is admitted for further alcohol and drug treatment services.