Wash. Admin. Code § 388-877-0640 - Clinical-Additional record content
Each agency licensed by the department to provide any behavioral health service is responsible for an individual's clinical record content. The clinical record must include:
(1) Documentation the individual received a
copy of counselor disclosure requirements as required for the counselor's
credential;
(2) Demographic
information;
(3) An
assessment;
(4) Documentation of
the individual's response when asked if:
(a)
The individual is under department of corrections (DOC) supervision;
(b) The individual is under civil or criminal
court ordered mental health or substance use disorder treatment; and
(c) There is a court order exempting the
individual participant from reporting requirements. A copy of the court order
must be included in the record if the participant claims exemption from
reporting requirements;
(5) Documentation that the agency is in
compliance with
RCW
71.05.445 regarding mental health services
for individuals under department of corrections supervision;
(6) Documentation the individual was informed
of applicable federal and state confidentiality requirements;
(7) Documentation of confidential information
that has been released without the consent of the individual under:
(a)RCW
70.02.050;
(b) The Health Insurance Portability and
Accountability Act (HIPAA); and
(c)RCW
70.02.230 and
70.02.240 if the individual received mental health treatment services;
(8) Documentation that any
mandatory reporting of abuse, neglect, or exploitation consistent with chapters
26.44 and 74.34 RCW has occurred;
(9) If treatment is not court-ordered,
documentation of informed consent to treatment by the individual or
individual's parent, or other legal representative;
(10) If treatment is court-ordered, a copy of
the order;
(11) Medication records,
if applicable;
(12) Laboratory
reports, if applicable;
(13)
Properly completed authorizations for release of information, if
applicable;
(14) Copies of
applicable correspondence;
(15)
Discharge information as follows:
(a) A
discharge statement if the individual left without notice;
(b) Discharge information for an individual
who did not leave without notice, completed within seven working days of the
individual's discharge, including:
(i) The
date of discharge;
(ii) Continuing
care plan;
(iii) Legal status, and
if applicable; and
(iv) Current
prescribed medication.
(c) When an individual is transferring to
another service provider, documentation that copies of documents pertinent to
the individual's course of treatment were forwarded to the new service provider
with the individual's permission;
(16) A copy of any report required by
entities such as the courts, department of corrections, department of
licensing, and the department of social and health services, and the date the
report was submitted;
(17) Progress
notes must include the date, time, duration, participant's name, response to
interventions, and a brief summary of the session and the name and credential
of the staff member who provided it;
(18) Documentation of coordination with any
systems or organizations the individual identifies as being relevant to
treatment, with the individual's consent or if applicable, the consent of the
individual's parent or legal representation; and
(19) A crisis plan, if one has been
developed.
Notes
Statutory Authority: Chapters 70.02, 70.96A, 71.05, 71.24, 71.34, 74.50 RCW, RCW 74.08.090, 43.20A.890, and 42 C.F.R. Part 8. WSR 13-12-054, § 388-877-0640, filed 5/31/13, effective 7/1/13.
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