Authority: IC 12-9-2-3; IC 12-11-1.1-9; IC 12-11-2.1-12

Affected: IC 12-11-1.1; IC 12-11-2.1

Sec. 8. (a) The provider identified in section 1 of this rule shall maintain a personal file for an individual at the provider's office. The file shall contain documentation of any change in an individual's physical condition, mental status, or any unusual event, including the following:

1. (1) Vomiting.
2. (2) Choking.
3. (3) Falling.
4. (4) Disorientation or confusion.
5. (5) Patterns of behavior.
6. (6) Seizures.

(b) The documentation of a change or event required by subsection (a) shall include:

1. (1) dates, times, and duration of the change or event;
2. (2) a description of the response of the provider, or the provider's employees or agents to the change or event; and
3. (3) the signature of the person or persons observing the change or event.

(c) A provider or providers working with an individual shall supply to the provider identified in section 1 of this rule any information regarding any change or event listed in subsection (a) that is observed while the provider is providing services to the individual.

(d) Except as provided in subsection (e), a provider observing a change in an individual's physical condition or mental status, or any unusual event, shall supply the information required in subsection (c) to the provider identified in section 1 of this rule as follows:

1. (1) within twenty-four (24) hours of the change or event; or
2. (2) by noon on the next business day;

whichever is later.

(e) If the change in an individual's physical condition or mental status or the unusual event is also a reportable incident under 460 IAC 6-9-5, the information shall be provided within twenty-four (24) hours.

(Division of Disability, Aging, and Rehabilitative Services; 460 IAC 6-25-8; filed Nov 4, 2002, 12:04 p.m.: 26 IR 782; readopted filed Sep 26, 2008, 11:11 a.m.: 20081015-IR-460080618RFA; readopted filed Aug 11, 2014, 11:20 a.m.: 20140910-IR-460140241RFA; readopted filed Nov 9, 2020, 3:08 p.m.: 20201209-IR-460200501RFA)