Record Requirements

(1) The service recipient’s record must contain the following information: (a) Documentation of the IPP and the Individualized Education Program (IEP), if required, and their implementation; (b) Daily progress notes which include written documentation of service recipient progress and changes which have occurred within the IPP. The progress notes must be dated and include the signature, title or degree of the person who provided the service; (c) Documentation on a medications log sheet of all drugs prescribed and/or administered by the facility with date prescribed, type, dosage, frequency, amount, and reason; (d) Narrative summary review at least every thirty (30) days of all medications prescribed which includes specific reasons for prescribing and continuation of each medication; (e) Documentation of significant behavior and actions taken by staff; (f) A list of each article of the service recipient’s personal property valued at one hundred dollars ($100.00) or more, and its disposition if no longer in use; (g) Documentation of abuse, medical problems, accidents, seizures, and illnesses and treatment for such abuse, medical problems, accidents, seizures, and illnesses, and any reports generated as the result; (h) Results of assessments required by this Rule; (i) Discharge summary which states the date of discharge, reasons for discharge, service recipient’s condition at the time of discharge, referral for other services, if appropriate, and signature of person preparing the summary; (j) Documentation of an education plan developed for each service recipient that conforms to the Rules, Regulations, and Minimum Standards of the State Board of Education and the IEP test being developed by an appropriately constituted IEP-Team for all “qualified students with disabilities.” The education plan may include education services provided either by the facility or by the local education agency; (k) 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 declined 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; MINIMUM PROGRAM REQUIREMENTS FOR ALCOHOL AND DRUG CHAPTER 0940-05-46 RESIDENTIAL TREATMENT FACILITIES FOR CHILDREN AND YOUTH (l) Appropriate authorizations for the release and obtaining of information about the service recipient; and (m) Contact person and means of contact in case of emergency.