37.106.1719 PATIENT ASSESSMENTS
(1) The facility shall utilize a multidisciplinary team which may include but is not limited to the patient, social workers, addiction counselors, licensed mental health professionals, licensed practical nurses, mental health technicians, peer support staff, registered nurses, psychologists, case managers, certified mental health professional persons, clergy, and family members.
(2) Each facility shall initiate a clinical intake assessment within 12 hours after admission for program services. Intake assessments must be conducted by a licensed mental health professional or licensed health care professional trained in clinical assessments and must include the following information in a narrative form to substantiate the patient's diagnosis and provide sufficient detail to individualize treatment plan goals and objectives:
(a) presenting problem and history of problem;
(b) mental status;
(c) diagnostic impressions;
(d) initial treatment plan goals;
(e) risk factors to include suicidal or homicidal ideation;
(f) psychiatric history;
(g) substance use/abuse and history;
(h) current medication and medical history;
(i) financial resources;
(j) family relationships;
(k) housing history and housing arrangements;
(l) nutritional needs;
(m) cultural and spiritual needs;
(n) education and/or work history;
(o) legal history relevant to history of illness, including guardianships, civil commitments, criminal mental health commitments, current and prior criminal background, and current legal status; and
(p) anticipated discharge needs.
(3) Based on the patient's clinical needs, the facility shall conduct additional assessments which may include, but are not limited to, physical, psychological, emotional, behavioral, psychosocial, recreational, vocational, psychiatric, and chemical dependency evaluations.