1. (1) The individual record for each service recipient must contain the following information:

   1. (a) Intake interview and initial physical assessment.
   2. (b) A signed and dated original consent for treatment including documentation of informed consent for the administration of medication, if applicable.
   3. (c) The report of the mental status examination and other mental health assessments, as appropriate.
   4. (d) Daily progress notes by the qualified prescriber, nurses and other mental health professionals, as applicable;
   5. (e) Laboratory and radiology results, if applicable.
   6. (f) Documentation of all contacts with external medical and other services.
   7. (g) Original documentation of all crisis stabilization service physician medication orders.
   8. (h) A discharge summary with prognosis justified by explanation.
   9. (i) List of personal property, including its disposition if no longer with the service recipient.
   10. (j) Documentation of significant behavioral events and actions taken by staff.
   11. (k) Documentation of discharge disposition, including aftercare arrangements, if applicable.

Authority: T.C.A. §§4-4-103, 4-5-202, 4-5-204, 33-1-302, 33-1-305, 33-1-309, 33-2-301, 33-2-302 and 33-2-404. Administrative History: Original rule filed May 26, 1988; effective July 11, 1988. Amendment filed September 4, 2003; effective November 18, 2003. Amendment filed July 31, 2008; effective October 14, 2008.