Service Recipient Record Requirements

(1) The individual’s service recipient record must include the following: (a) Documentation on a medications log sheet of all medications prescribed or administered including date, type, dosage, frequency, amount, and reason; (b) Documentation of a treatment protocol and schedule for detoxification and notes by qualified alcohol and drug or medical personnel that the protocol and schedule is being followed or exceptions to the protocol and schedule; (c) For facilities providing Level II-D extended on-site monitoring, documentation of daily (seven days per week) nursing assessments of withdrawal, progress during detoxification, and any treatment changes; (d) Reports of medical problems, accidents, seizures, illnesses and treatments for such accidents, seizures, and illnesses; (e) Reports of significant behavior incidents; (f) Reports of any instance of physical holding or restrictive procedures with documented justification and authorization; and (g) A discharge plan which states the date of discharge, status at discharge, reasons for discharge, and referral of the service recipient and their family or significant others to other services, as appropriate.