Tenn. Comp. R. & Regs. 0940-05-41-.08 - SERVICE RECIPIENT RECORD REQUIREMENTS
(1) The
individual service recipient record must include the following:
(a) Documentation on a medications log sheet
of all medications prescribed or administered with the date of the
prescription, date of administration, type, dosage, frequency, amount, and
reason;
(b) Documentation of the
service recipient's employment related problem or problems and goal or goals on
the IPP, and the service recipient's progress or lack of progress towards
meeting the goal or goals in the progress notes, or clinical justification for
an exception to the policy and procedure;
(c) A list of each individual article of each
service recipient's personal property valued at one hundred dollars ($100.00)
or more including its disposition, if no longer in use;
(d) Written accounts of all monies received
and disbursed on behalf of the service recipient;
(e) Reports of medical problems, accidents,
seizures, and illnesses and treatments for such accidents, seizures, and
illnesses;
(f) Reports on
significant behavior incidents;
(g)
Reports of any instance of physical holding or restriction with documented
justification and authorization;
(h) A discharge summary which states the date
of discharge, reasons for discharge, and referral for other services, if
appropriate; and
(i) An aftercare
plan which specifies the type of contact, planned frequency of contact, and
responsible staff; or documentation that the service recipient was offered
aftercare but decided not to participate; or documentation that the service
recipient dropped out of treatment and is therefore not available for aftercare
planning; or verification that the service recipient is admitted for further
alcohol and drug treatment services.
Notes
Authority: T.C.A. ยงยง 4-4-103, 4-5-202, 4-5-204, 33-1-302, 33-1-305, 33-1-309, 33-2-301, 33-2-302, 33-2-404, and Executive Order 44 (February 23, 2007).
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