37.106.1983 OUTPATIENT CRISIS RESPONSE FACILITY: CLINICAL RECORDS
(1) Each crisis response facility shall collect assessment data and maintain clinical records on all clients who receive services.
(2) Each facility must ensure the confidentiality of clinical records in accordance with the Health Information Portability and Accountability Act (HIPAA) .
(3) At a minimum, the clinical record must include:
(a) a clinical intake assessment;
(b) additional assessments or evaluations, if clinically indicated;
(c) a copy of the client's individualized crisis treatment plan and all modifications to the crisis treatment plan;
(d) progress notes which indicate whether or not the stated treatment plan has been implemented, and the degree to which the client is progressing, or failing to progress, toward stated treatment objectives;
(e) medication orders from the prescribing physician and documentation of the administration of all medications;
(f) signed orders by a licensed mental health professional for any restrictions of rights; and, privileges accorded clients of the crisis response facility including the reasons for the restriction; and
(g) a discharge summary which must be completed within one week of the date of discharge.