1. (1) The individual service recipient record must include the following:

   1. (a) Documentation of all drugs prescribed or administered to the service recipient as part of the plan of care indicating the date prescribed, type, dosage, frequency, amount, and reason;
   2. (b) Narrative summary review at least every ninety (90) days of all medications prescribed which includes specific reasons for prescribing and continuation of each medication;
   3. (c) A discharge summary which states the date of discharge, reasons for discharge, and referral for other services, if appropriate;
   4. (d) An aftercare plan which specifies the type of contact, planned frequency of contact, and responsible staff; or documentation that the service recipient was offered aftercare but decided not to participate; or documentation that the service recipient dropped out of treatment and is therefore not available for aftercare planning; or verification that the service recipient is admitted for further alcohol and drug treatment services; and DRUG NON-RESIDENTAL REHABILITATION TREATMENT FACILITIES
   5. (e) Documentation of any instance of restraint or restriction with documented justification and authorization.

Authority: T.C.A. §§ 4-4-103, 4-5-202, 33-1-302, 33-1-305, 33-1-309, 33-2-301, 33-2-302, and 33-2-404 and Executive Order 44 (February 23, 2007). Administrative History: Original rule filed April 27, 2000; effective July 11, 2000. Amendment filed April 30, 2003; effective July 14, 2003. Amendment filed June 21, 2007; effective September 4, 2007. On May 15, 2008, rule was transferred from 1200-08-18 per Executive Order 44 (February 23, 2007). Repeal and new rule filed July 31, 2008; effective October 14, 2008.