1. (a) An admission note shall be completed within 24 hours of admission which includes, but need not be limited to:

   1. (1) reason for admission;
   2. (2) present condition of the client reported in objective, behavioral terms, and when possible, a description of the client's condition by others;
   3. (3) diagnostic impression, including a provisional or admitting diagnosis;
   4. (4) determination of and request for additional referrals or special diagnostic tests, assessments or evaluations, if needed; and
   5. (5) a preliminary individual treatment or habilitation plan.
2. (b) If clinically indicated, a social, educational, medical, criminal, vocational, developmental, and psychiatric history shall be completed within 30 days after admission.

History Note: Authority G.S. 148‑19(d);
Eff. January 4, 1994;
Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. June 20, 2015.