- (a) The crisis stabilization unit shall have a policy and procedure mandating the chronological documentation of progress notes for clients admitted to crisis stabilization units.
(b) Progress notes shall minimally address the following:
- (1) Person or persons to whom services were rendered;
- (2) Activities and services provided and as they relate to the goals and objectives of the intervention plan, including ongoing reference to the intervention plan;
- (3) Documentation of the progress or lack of progress in crisis resolution as defined in the intervention plan;
- (4) Documentation of the intervention plan's implementation, including client activities and services;
- (5) The client's current status;
(6) Documentation of the client's:
- (A) Response to intervention services;
- (B) Changes in behavior and mood; and
- (C) Outcome of intervention services; and
- (7) Plans for continuing therapy or for discharge, whichever is appropriate.
(c) Progress notes shall be documented according to the following timeframes:
- (1) Intervention team shall document progress notes daily; and
- (2) Nursing service shall document progress notes on each shift.