Clinical record content — Intake and assessment
Arkansas Code § 20-76-201; Arkansas Code § 20-77-107; Arkansas Code § 25-10-129
(a)
- (1) The therapeutic community shall assess each individual to determine appropriateness of admission.
- (2) Initial assessments by an MHP are to be completed on all clients.
(b) Client intake information shall contain, but not be limited to the following identification data:
- (1) Client name;
- (2) Name and identifying information of the legal guardian or guardians;
- (3) Home address;
- (4) Telephone number;
- (5) Referral source;
- (6) Reason for referral;
- (7) Significant other to be notified in case of emergency;
- (8) Intake data core content;
- (9) Presenting problem and disposition;
(10) A record of pertinent information regarding adverse reactions to drugs, drug allergies, or sensitivities shall be:
- (A) Obtained during intake; and
- (B) Kept in a highly visible location in or on the record; and
- (11) Screening for co-occurring disorders, trauma, medical, and legal issues.
(c)
- (1) Client assessment information for clients admitted to therapeutic communities shall be completed within twelve (12) hours of admission.
(2) Integrated mental health and substance abuse psychosocial evaluation that minimally addresses:
- (A) The client's strengths and abilities to be considered during community reentry; and
- (B) Economic, vocational, educational, social, family, and spiritual issues as indicated.
- (3) Interpretive summary of relevant assessment findings that results in the development of an intervention plan addressing mental health, substance use disorder, and other related issues contributing to admission to a therapeutic community.
(4) An integrated intervention plan that minimally addresses the client's:
- (A) Presenting crisis situation that incorporates the identified problem or problems;
- (B) Strengths and abilities;
- (C) Needs and preferences; and
- (D) Goals and objectives.