42 C.F.R. § 456.180 – Individual written plan of care.

(a) Before admission to a mental hospital or before authorization for payment, the attending physician or staff physician must establish a written plan of care for each applicant or beneficiary.
(b) The plan of care must include—
1. (1) Diagnoses, symptoms, complaints, and complications indicating the need for admission;
2. (2) A description of the functional level of the individual;
3. (3) Objectives;
4. (4) Any orders for—
  1. (i) Medications;
  2. (ii) Treatments;
  3. (iii) Restorative and rehabilitative services;
  4. (iv) Activities;
  5. (v) Therapies;
  6. (vi) Social services;
  7. (vii) Diet; and
  8. (viii) Special procedures recommended for the health and safety of the patient;
5. (5) Plans for continuing care, including review and modification to the plan of care; and
6. (6) Plans for discharge.
(c) The attending or staff physician and other personnel involved in the beneficiary's care must review each plan of care at least every 90 days.