(c) All individuals receiving services from the comprehensive psychiatric emergency program must have a case record which, at a minimum, includes a presentation note which indicates:

1. (1) a brief description of the presenting problem, critical needs and overall conditions;
2. (2) a brief description of the care and treatment required to safely and effectively address the individual's needs during the initial period after admission; and
3. (3) a brief description of the comprehensive psychiatric emergency program’s attempts to contact collaterals.

(d) In addition to the information called for in subdivision (c) of this section, each case record for individuals who receive a triage and referral visit, a full emergency visit, or are admitted to an extended observation bed or receive crisis outreach shall include:

1. (1) patient identifying information and available psychiatric medical and relevant social history, including the person's residential situation and the details of the circumstances leading to the individual's presentation at the comprehensive psychiatric emergency program, and the name of the person or persons who have referred or brought the individual to the comprehensive psychiatric emergency program, if any. In the case of individuals brought to the comprehensive psychiatric emergency program by law enforcement officers, the officers should be interviewed and identified in the case record;
2. (2) diagnosis;
3. (3) assessment of the patient's treatment needs based upon psychiatric, physical, social and functional evaluations; and
4. (4) progress notes which relate to goals and objectives of treatment and document services provided.

(e) The following information is required for each case record for individuals who receive a full emergency visit and/or is admitted to an extended observation bed and may be included in the case record for individuals who receive a triage and referral visit and/or crisis outreach:

1. (1) reports of all mental and physical diagnostic exams, assessments, tests, and consultations;
2. (2) notes which relate to special circumstances and untoward incidents;
3. (3) dated and signed orders for all medications;
4. (4) discharge summary, including referrals to other programs and services, which must be completed within five days of discharge; and
5. (5) documentation of attempts to contact collaterals.