20 CAR § 433-312 – Progress notes

(a) Progress notes shall contain:
1. (1) The date and time the session ended;
2. (2) The purpose of the session;
3. (3) Topics discussed;
4. (4) Client behavior and response to the treatment provided during the session;
5. (5) Significant events; and
6. (6) The name, signature, and title of the staff person conducting the session.
(b) Group and individual treatment sessions progress shall be documented per session.
(c) Outpatient treatment is documented per session.
(d) Partial day treatment notes contain information required by but may be compressed into a single note that addresses treatment provided on a per-day basis.
(e) Residential treatment shall be documented at least daily.
(f) The client’s progress in meeting treatment plan goals will be assessed at the time of discharge.
(g)
1. (1) Significant client events that fall within the provisions of the "Incident Reporting Policy" shall be documented as soon as possible after the event.
2. (2) The administration of first aid to a client shall be documented as soon as possible.
3. (3) Any client behavior that could lead to a disciplinary action shall be documented as soon as possible.
4. (4) Any other event that could affect the client's treatment shall be documented as soon as possible.
(h) When a client refuses to divulge information and/or follow the recommended course of treatment, this refusal is noted in the case client record.
(i) When a client transfers from one program to another, the transferring program shall send copies of the transferring client’s records to the licensed receiving program prior to admission.