The patient record shall contain documentation of physical rehabilitation services utilized that include but is not limited to:

1. (1) diagnosis to support the services requested;
2. (2) assessment of patient's rehabilitative status;
3. (3) re-assessment and progress of patient's rehabilitative status;
4. (4) individualized plan of care and goals of rehabilitation; and
5. (5) discharge plan.

History Note: Authority G.S. 131E-79;
Eff. January 1, 1996;
Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 22, 2017.