Subd. 1. Generally.

A license holder must ensure that all documentation required by this chapter complies with this section.

Subd. 2. Documentation standards.

A license holder must ensure that all documentation required by this chapter:

1. (1) is legible;
2. (2) identifies the applicable client name on each page of the client file and staff person name on each page of the personnel file; and
3. (3) is signed and dated by the staff persons who provided services to the client or completed the documentation, including the staff persons' credentials.

Subd. 3. Documenting approval.

A license holder must ensure that all diagnostic assessments, functional assessments, level of care assessments, and treatment plans completed by a clinical trainee or behavioral health practitioner contain documentation of approval by a treatment supervisor within ten business days of initial completion by the staff person under treatment supervision.

Subd. 4. Progress notes.

A license holder must use a progress note to document each occurrence of a mental health service that a staff person provides to a client. A progress note must include the following:

1. (1) the type of service;
2. (2) the date of service;
3. (3) the start and stop time of the service unless the license holder is licensed as a residential program;
4. (4) the location of the service;
5. (5) the scope of the service, including: (i) the targeted goal and objective; (ii) the intervention that the staff person provided to the client and the methods that the staff person used; (iii) the client's response to the intervention; and (iv) the staff person's plan to take future actions, including changes in treatment that the staff person will implement if the intervention was ineffective;
6. (6) the signature and credentials of the staff person who provided the service to the client;
7. (7) the mental health provider travel documentation required by section 256B.0625, if applicable; and
8. (8) significant observations by the staff person, if applicable, including: (i) the client's current risk factors; (ii) emergency interventions by staff persons; (iii) consultations with or referrals to other professionals, family, or significant others; and (iv) changes in the client's mental or physical symptoms.

Subd. 5. Medication administration record.

If a license holder administers or observes a client self-administer medications, the license holder must maintain a medication administration record for each client that contains the following, as applicable:

1. (1) the client's date of birth;
2. (2) the client's allergies;
3. (3) all medication orders for the client, including client-specific orders for over-the-counter medications and approved condition-specific protocols;
4. (4) the name of each ordered medication, date of each medication's expiration, each medication's dosage frequency, method of administration, and time;
5. (5) the licensed prescriber's name and telephone number;
6. (6) the date of initiation;
7. (7) the signature, printed name, and credentials of the staff person who administered the medication or observed the client self-administer the medication; and
8. (8) the reason that the license holder did not administer the client's prescribed medication or observe the client self-administer the client's prescribed medication.