0940-05-43-.08
Service Recipient Record Requirements
Cite as Tenn. Comp. R. & Regs. 0940-05-43-.08
(1)
The individual service recipient record must include the following:
(a)
Documentation of all drugs prescribed or administered to the service recipient as part
of the plan of care indicating the date prescribed, type, dosage, frequency, amount,
and reason;
(b)
Narrative summary review at least every ninety (90) days of all medications prescribed
which includes specific reasons for prescribing and continuation of each medication;
(c)
A discharge summary which states the date of discharge, reasons for discharge, and
referral for other services, if appropriate;
(d)
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; and
MINIMUM PROGRAM REQUIREMENTS FOR ALCOHOL AND
CHAPTER 0940-05-43
DRUG NON-RESIDENTAL REHABILITATION TREATMENT FACILITIES
(e)
Documentation of any instance of restraint or restriction with documented justification
and authorization.