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

   1. (a) Documentation on a medications log sheet of all medications prescribed or administered with the date of the prescription, date of administration, type, dosage, frequency, amount, and reason;
   2. (b) Narrative summary review at least every thirty (30) days of all medications prescribed which includes specific reasons for prescribing and continuing each medication;
   3. (c) A list of each individual article of each service recipient’s personal property valued at $100.00 or more including disposition, if no longer in use;
   4. (d) Written accounts of all monies received and disbursed on behalf of the service recipient;
   5. (e) Reports of health history, past and current;
   6. (f) Reports of aggressive and/or disruptive behavior incidents; ABUSE RESIDENTIAL REHABILITATION TREATMENT FACILITIES
   7. (g) Reports of any instance of physical holding or restriction with documented justification and authorization;
   8. (h) A discharge summary which states the date of discharge, reasons for discharge, status of the service recipient at the time of discharge and referral for other services, if appropriate; and
   9. (i) 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 referred for further alcohol and drug treatment services.

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 and Executive Order 44 (February 23, 2007). Administrative History: Original rule filed April 27, 2000; effective July 11, 2000. Repeal and new rule filed January 3, 2006; effective March 19, 2006. Amendment filed June 21, 2007; effective September 4, 2007. On May 15, 2008, rule was transferred from 1200-08-17 per Executive Order 44 (February 23, 2007). Repeal and new rule filed August 27, 2008; effective November 10, 2008.