1. (a) The clinical record shall be designed to:

   1. (1) Document the medical necessity for services provided;
   2. (2) Document the response to and effectiveness of services;
   3. (3) Document the extent of coordination of care by system-wide providers and, when appropriate, with providers outside the mental health system; and
   4. (4) Provide documentation substantiating the delivery and appropriateness of services as required by He-M 401 and He-M 426.

2. (b) The clinical record shall include, at a minimum, the following components:

   1. (1) Intake and assessment information in accordance with He-M 408.06;
   2. (2) Demographic data in accordance with He-M 408.05;
   3. (3) Annual notification of an individual’s rights in accordance with He-M 309;
   4. (4) Documentation of eligibility determination in accordance with He-M 401;
   5. (5) Individual service planning documentation pursuant to He-M 401;
   6. (6) Individual service plan;
   7. (7) Documentation of service delivery and outcomes;
   8. (8) Suspension, transfer, and discharge notes, if applicable;
   9. (9) Documentation of ISP reviews;
   10. (10) Medication orders, laboratory results, and general health information;
   11. (11) Pertinent legal data;
   12. (12) Admission and discharge reports from mental health facilities and from other providers, when applicable; and

   13. (13) Targeted case management assessment and care plan pursuant to He-M 426, which shall include documentation of the following, when applicable:

       1. a. Identification of the individual’s targeted case management needs;
       2. b. The referral and monitoring activities to be provided; and
       3. c. An individual’s refusal to receive specific services in the care plan.

Source. #2039, eff 7-1-82; ss by #2423, eff 7-13-83; rpld by #2468, eff 9-6-83 New. #3051, eff 7-8-85, EXPIRED: 7-8-91 New. #7281, eff 5-23-00, EXPIRED: 5-23-08 New. #9512 eff 7-9-09; ss by #12409, eff 10-24-17