(1) An EDC's clinical records must contain the following:

(a) the name, address, date of birth, and gender of the client;

(b) the name and contact information for the client's family and any
legally authorized representative;

(c) be in the preferred language and include any special communication needs of the client;

(d) a reason of admission for care, treatment, or services;

(e) an initial screening assessment;

(f) a clinical intake assessment;

(g) medical information including results of physical exam and laboratory testing;

(h) an initial plan of care and plan of care reviews;

(i) documentation of individual, family, and group therapy;

(j) documentation of family involvement or reason why involvement is contraindicated;

(k) documentation of consultations with a registered dietitian;

(l) documentation of monitoring the client's weight and food related behaviors as outlined in the plan of care; and

(m) a discharge summary.


History: 50-5-247, MCA; IMP, 50-5-247, MCA; NEW, 2018 MAR p. 2214, Eff. 11/3/18.