(a) Social history/assessment.

1. (1) Should give clear picture of individual over life span to date.
2. (2) Incomplete information should specify reason for such.

3. (3) Reflects current:

   1. (A) Functioning level;
   2. (B) Limitations;
   3. (C) Strengths; and
   4. (D) Weaknesses.

(b) Progress notes.

1. (1) Important happenings shall be entered promptly into social services’ progress record.
2. (2) At least a quarterly update shall be done.

(c) Referral form.

1. (1) Pertains to referrals for social/emotional needs rather than medical.
2. (2) May be a separate form or reflected in progress notes.

(d) Resident rights.

1. (1) Appropriately signed by a:

   1. (A) Resident capable of understanding: signs with one (1) witness;
   2. (B) Resident incompetent:

(i) Legal documentation of such; and

1. (ii) Guardian and one (1) witness sign patient’s rights;

   1. (C) Resident incapable because of illness:

      1. (i) Doctor must write statement saying why resident cannot understand; and
      2. (ii) Responsible party and two (2) witnesses sign; or

   2. (D)

      1. (i) Resident with intellectual disabilities: rights read and if he or she understands, resident signs along with staff member and outside disinterested party.
      2. (ii) If he or she cannot understand, rights explained to and signed by guardian and witness.
2. (2) Copies posted around the facility.
3. (3) Staff members who administer rights must understand them fully.
4. (4) Facility staff must understand patients’ rights and respect them.