Service Recipient Record Requirements

(1) The 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) Narrative summary review at least every thirty (30) days of all medications prescribed which includes specific reasons for prescribing and continuing each medication; (c) A list of each individual article of each service recipient’s personal property valued at $100.00 or more including disposition, if no longer in use; (d) Written accounts of all monies received and disbursed on behalf of the service recipient; (e) Reports of health history, past and current; (f) Reports of aggressive and/or disruptive behavior incidents; MINIMUM PROGRAM REQUIREMENTS FOR ALCOHOL AND DRUG CHAPTER 0940-05-45 ABUSE RESIDENTIAL REHABILITATION TREATMENT FACILITIES (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, status of the service recipient at the time of 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 referred for further alcohol and drug treatment services.