Service Recipient Record Requirements

(1) The individual service recipient record must include the following: MINIMUM PROGRAM REQUIREMENTS FOR ALCOHOL AND CHAPTER 0940-05-44 DRUG RESIDENTIAL DETOXIFICATION TREATMENT FACILITIES (a) Documentation on a medications log sheet of all medications prescribed or administered including date, type, dosage, frequency, amount, and reason; (b) A list of each individual article of each service recipient’s personal property valued at $100.00 or more including its disposition, if no longer in use; (c) Written accounts of all monies received and disbursed on behalf of the service recipient; (d) Reports of medical problems, accidents, seizures, and illnesses and treatments for such accidents, seizures, and illnesses; (e) Reports of significant behavior incidents; (f) Reports of any instance of physical holding, restrictive procedures, or restraint with documented justification and authorization; (g) A discharge summary which states the date of discharge, status at discharge, reasons for discharge, and referrals of service recipients and their families or significant others to the appropriate treatment resource upon completion of detoxification as appropriate; and (h) Documentation of a treatment protocol for detoxification and daily notes, seven (7) days per week, by qualified alcohol and drug or medical personnel that the protocol is being followed or exceptions to the protocol.