(1) Each mental health center shall prepare a discharge summary for each client no longer receiving services. The discharge summary must include:

(a) the reason for discharge;

(b) a summary of the services provided by the mental health center including recommendations for aftercare services and referrals to other services, if applicable;

(c) an evaluation of the client's progress as measured by the treatment plan and the impact of the services provided by the mental health center; and

(d) the signature of the staff member who prepared the report and the date of preparation.

(2) Discharge summaries reports must be filed in the clinical record within one month of the date of the client's formal discharge from services or within three months of the date of the client's last service when no formal discharge occurs.

(3) For cases left open when a client has not received services for over 30 days, documentation must be entered into the record indicating the reason for leaving the case open.

History: 50-5-103, MCA; IMP, 50-5-103, 50-5-204, MCA; NEW, 1998 MAR p. 539, Eff. 2/27/98; TRANS & AMD, 2002 MAR p. 916, Eff. 3/29/02.