1. (1) An EDC's clinical records must contain the following:

   1. (a) the name, address, date of birth, and gender of the client;
   2. (b) the name and contact information for the client's family and any
      legally authorized representative;
   3. (c) be in the preferred language and include any special communication needs of the client;
   4. (d) a reason of admission for care, treatment, or services;
   5. (e) an initial screening assessment;
   6. (f) a clinical intake assessment;
   7. (g) medical information including results of physical exam and laboratory testing;
   8. (h) an initial plan of care and plan of care reviews;
   9. (i) documentation of individual, family, and group therapy;
   10. (j) documentation of family involvement or reason why involvement is contraindicated;
   11. (k) documentation of consultations with a registered dietitian;
   12. (l) documentation of monitoring the client's weight and food related behaviors as outlined in the plan of care; and
   13. (m) a discharge summary.

Authorizing statute(s): 50-5-247, MCA

Implementing statute(s): 50-5-247, MCA

History: NEW, 2018 MAR p. 2214, Eff. 11/3/18.