W. Va. Code R. § 69-7-35 - Documentation of Patient Contact

35.1. The primary counselor or medical staff is responsible for documentation of significant contact with each patient, which shall be filed in the patient record.

35.2. The documentation shall include a description of:

35.2.a. The reason for or nature of the contact;

35.2.b. The patient's current condition;

35.2.c. Significant events occurring since prior contact;

35.2.d. The assessment of patient status; and

35.2.e. A plan for action or further treatment.

35.3. Each entry shall be completed within twenty-four hours of the contact and shall be clearly dated and initialed or signed by the staff person involved.

Notes

W. Va. Code R. § 69-7-35