10A NCAC 13B .5204. PSYCHIATRIC OR SUBSTANCE ABUSE SERVICES RECORD REQUIREMENTS

(a)  In addition to the general record keeping requirements of 10A NCAC 13B .3906, specialized assessment and treatment plans for individuals undergoing psychiatric or substance abuse treatment are as follows:

(1)           Within 24 hours following admission each individual shall have a completed admission assessment.  The initial assessment shall include the reason for admission, admitting diagnosis, mental status including suicide potential, diagnostic tests or evaluations, and a determination of the need for additional information to include the potential for the physical abuse of self or others and a family assessment when a minor is involved;

(2)           Within 72 hours following admission, a preliminary individual treatment plan shall be completed and implemented; and

(3)           Within five days following admission, a comprehensive individual treatment plan shall be developed and implemented.  For outpatient services, the plan shall be developed and implemented within 30 days of admission to treatment.

(b)  Individual treatment plans for psychiatric and substance abuse patients shall be developed in partnership with the patient or individual acting on behalf of the patient.  Clinical responsibility for the development and implementation of the plan shall be clearly designated.  Minimum components of the comprehensive treatment plan shall include diagnosis and time specific short and long term measurable goals, strategies for reaching goals, and staff responsibility for plan implementation.  The plan shall be revised as medically or clinically indicated.

(c)  Progress notes shall be entered in each individual's record.  Included is information which may have a significant impact on the individual's condition or expected outcome such as family conferences or major events related to the patient.  Patient status shall be documented each shift for any inpatient psychiatric or substance abuse services, and on a per visit basis for outpatient psychiatric and substance abuse services.

(d)  For each individual to whom substance abuse services are provided, a written plan for aftercare services shall be developed which minimally includes:

(1)           plan for delivering aftercare services, including the aftercare services which are provided; and

(2)           provision for agreements with individuals or organizations if aftercare services are not provided directly by the facility.

 

History Note:        Authority G.S. 131E-79;

Eff. January 1, 1996.