Tenn. Comp. R. & Regs. 0940-05-30-.06 - CLIENT RECORD REQUIREMENTS FOR INTENSIVE DAY TREATMENT PROGRAM FACILITIES
The individual record for each client must contain the following information:
(1)
Documentation of the IPP and the IEP (if required) and of their
implementation;
(2) Progress notes
which must be developed after each service contact, and which must include
written documentation of client progress or changes which have occurred within
the IPP;
(3) Documentation of all
drugs prescribed or administered by the facility which indicates date
prescribed, type, dosage, frequency, amount, and reason;
(4) Narrative summary review of all
medications prescribed at least every six (6) months which includes specific
reasons for continuation of each medication;
(5) Results of assessments required by Rule
0940-5-30-.03; and
(6) Discharge
summary which states, if appropriate, client condition at the time of discharge
and signature of person preparing the summary.
Notes
Authority: T.C.A. ยงยง 4-4-103, 33-2-504 and 33-1-205(b)(5).
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