Clinical record content, intake, and assessment
Arkansas Code § 20-47-813
(a)
- (1) The crisis stabilization unit shall assess each individual to determine appropriateness of admission.
- (2) Initial assessments are to be completed on all clients voluntary or involuntary at time of entrance.
(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 obtained during intake and kept in a highly visible location in or on the record; and
- (11) Screening for co-occurring disorders, trauma, and medical and legal issues.
(c) Client assessment information for clients admitted to crisis stabilization units shall be completed within twelve (12) hours of client’s entrance:
(1) Integrated mental health and substance abuse psychosocial evaluation that minimally addresses:
- (A) The client's strengths and abilities to be considered during community reentry;
- (B) Economic, vocational, educational, social, family, and spiritual issues as indicated; and
- (C) An initial discharge plan;
- (2) 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 the crisis; and
(3) 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.