The individual record for each service
recipient must contain the following information:
(a) Intake interview and initial physical
(b) A signed and dated
original consent for treatment including documentation of informed consent for
the administration of medication, if applicable.
(c) The report of the mental status
examination and other mental health assessments, as appropriate.
(d) Daily progress notes by the qualified
prescriber, nurses and other mental health professionals, as
(e) Laboratory and
radiology results, if applicable.
(f) Documentation of all contacts with
external medical and other services.
(g) Original documentation of all crisis
stabilization service physician medication orders.
(h) A discharge summary with prognosis
justified by explanation.
of personal property, including its disposition if no longer with the service
(j) Documentation of
significant behavioral events and actions taken by staff.
(k) Documentation of discharge disposition,
including aftercare arrangements, if applicable.
Tenn. Comp. R. &
Original rule filed May
26, 1988; effective July 11, 1988. Amendment filed September 4, 2003; effective
November 18, 2003. Amendment filed July 31, 2008; effective October 14,
Authority: T.C.A. §§
4-5-202, 4-5-204, 33-1-302,
33-1-305, 33-1-309, 33-2-301, 33-2-302 and 33-2-404.