Service Recipient Record Requirements

(1) The individual record maintained for each service recipient shall contain the following information: (a) Marital status; (b) Social security number; (c) Medicaid and Medicare number; (d) Legal competency status, if available; (e) Source of financial support and financial arrangements for residing in the facility. This information shall be updated when the service recipient’s financial status changes; (f) Name, address and telephone number of the physician or health agency providing medical services; (g) A list of each individual article of the service recipient’s personal property valued at fifty dollars ($50.00) or more including its disposition, if no longer in use; (h) Written accounts of all monies received and disbursed on behalf of the service recipient; (i) Report of medical problems, accidents, seizures and illnesses and treatments for such accidents, seizures and illnesses; MINIMUM PROGRAM REQUIREMENTS FOR ADULT CHAPTER 0940-05-51 SUPPORTIVE RESIDENTIAL FACILITIES (j) Report of significant behavior incidents; (k) Notes made on a weekly basis which minimally include a brief statement of the service recipient’s progress while residing at the facility. The notes shall include the date that the note was written and the signature of the person making the note; (l) Current diagnosis and DSM axis, summary of mental health service plan and crisis plan; (m) Medication log; and (n) Housing transition plan.