1. (a) The psychiatric residential treatment facility shall initiate and maintain an onsite and organized record for each resident.

2. (b) The record shall contain sufficient documented information to:

   1. (1) Identify the resident, and the agency and the associated staff responsible for that resident;
   2. (2) Support the diagnosis, secure the appropriate care/services as needed; and

   3. (3) Justify the care/services provided to include:

      1. (A) The course of action taken and results;
      2. (B) The symptoms or other indications of sickness or injury;
      3. (C) Changes in physical, mental, or behavioral condition, or any combination thereof;
      4. (D) The response or reaction to care, medication, and diet provided; the results of the baseline data captured at the time of admission with a standardized tool designed to measure outcomes; data captured at the time of discharge and any data collected between admission and discharge; and
      5. (E) Promote continuity of care among providers, consistent with acceptable standards of practice.
3. (c) All entries shall be written legibly in ink, typed, or electronic media, and signed and dated.

4. (d) Specific entries and documentation shall include at a minimum:

   1. (1) Personal data sheet to include the following information, when obtainable:

      1. (A) Resident name;
      2. (B) Address;
      3. (C) Date of birth;
      4. (D) Gender;
      5. (E) Race;
      6. (F) Parent or legal guardian’s name;
      7. (G) Medicaid ID or PASSE ID;
      8. (H) Provisional diagnosis;
      9. (I) Days of care;
      10. (J) Social Security number;
      11. (K) Name, address, and telephone number of person or persons to be notified in the event of an emergency;
      12. (L) Name and address of referral source;
      13. (M) Name of attending physician;
      14. (N) Date and hour of admission; and
      15. (O) Consultations by physicians or other authorized healthcare providers;

   2. (2) Consents and acknowledgements. The provider shall obtain and maintain in the resident record all consents including:

      1. (A) Authority to place the child;
      2. (B) Consent for medical care;
      3. (C) Consent for administration of psychotropic medication;
      4. (D) Acknowledgement of restraint policy;
      5. (E) Consent or consents for restraint; and
      6. (F) Any additional consents as required by state or federal law, guidance, rules, or regulations;
   3. (3) Consultations by physicians or other authorized healthcare providers;

   4. (4)

      1. (A) Orders and recommendations for all medication, care, services, procedures, and diet from physicians or other authorized healthcare providers, which shall be completed prior to, or within forty-eight (48) hours after, admission and thereafter as warranted.
      2. (B) Verbal orders received shall be documented and include the date and time of receipt of the order, description of the order, and identification of the individual receiving the order.
      3. (C) Medication administration record or similar document for recording of medications, treatments, and other pertinent data and procedures followed if an error is made.
      4. (D) All treatment service documentation and progress notes must include, at a minimum, the following:

5. (i) An intake/intake assessment and diagnosis;

   1. (ii) Ongoing assessment and diagnosis;

      1. (iii) An individualized treatment plan;

         1. (iv) Staff ratio associated with the resident if on heightened ratio requirements;
         2. (v) Psychiatric services;
         3. (vi) Mental health therapy services;
         4. (vii) Milieu therapy;
         5. (viii) Recreational and therapeutic activities;
         6. (ix) Family involvement;
         7. (x) Visitation records; and
         8. (xi) Discharge planning;
      2. (E) Provisions for routine and emergency medical care, to include the name and telephone number of the resident’s physician, plan for payment, and plan for securing medications;
      3. (F) Special information, such as proof of legal guardianship status, allergies, power of attorney, or responsible party.

Codification Notes: "PASSE" means a Provider-Led Arkansas Shared Savings Entity.