R501-24-9. Client Records

(1) The provider shall maintain client records that include the intake assessment, any 15-minute check-in notes, and a discharge plan. (2) The provider shall maintain the documentation listed in Subsection (1) for at least 30 days after a client's last facility stay to reopen the client file if the client returns. (3)(a) The provider shall ensure each client record includes: (i) client information, including the client's: (A) name; (B) date of birth; (C) identified gender; (D) entrance date into the facility; (E) exit date from the facility; (F) phone number; (G) last known physical address; and (H) current email address; (ii) any emergency contact for the client, including the emergency contact's: (A) name; (B) phone number; (C) physical address; and (D) current email address; (iii) any information that could affect the health, safety or wellbeing of the client, including any: (A) allergy; (B) chronic condition; (C) communicable disease; and (D) medication needs; (iv) any grievance or complaint made by or against the client and any action taken by the program to address the grievance or complaint; (v) any critical incident report involving the client; and (vi) any signed agreement and consent form for the client to receive services, including any parent or legal guardian signature for a client under 18 years old. (b) If the provider cannot obtain any of the information listed in Subsection (3)(a), the client record shall document the reason why that information is not obtainable.