10A NCAC 26D .0902. ADMISSION ASSESSMENT

(a)  An admission note shall be completed within 24 hours of admission which includes, but need not be limited to:

(1)           reason for admission;

(2)           present condition of the client reported in objective, behavioral terms, and when possible, a description of the client's condition by others;

(3)           diagnostic impression, including a provisional or admitting diagnosis;

(4)           determination of and request for additional referrals or special diagnostic tests, assessments or evaluations, if needed; and

(5)           a preliminary individual treatment or habilitation plan.

(b)  If clinically indicated, a social, educational, medical, criminal, vocational, developmental, and psychiatric history shall be completed within 30 days after admission.

 

History Note:        Authority G.S. 148‑19(d);

Eff. January 4, 1994.