Compilation of Rules and Regulations of the State of Georgia
Department 82 - DEPARTMENT OF BEHAVIORAL HEALTH AND DEVELOPMENTAL DISABILITIES
Chapter 82-4
Subject 82-4-1 - CHILD AND ADOLESCENT CRISIS STABILIZATION UNITS
Rule 82-4-1-.11 - Documentation of Care

1.Record of evaluation for admission and outcome of the evaluation, including the date, time, name and credentials of the professional conducting the evaluation;

2.Legal status documents for admission and continued stay in the C & A CSU, as detailed in O.C.G.A. Secs. 37-3-1et seq. and 37-7-1 et seq;

3.Documentation of guardianship, whenever applicable;

4.Documentation of consent for services by the legal guardian;

5.Assessments, to include psychiatric, physical health, nursing and psychosocial status;

6.Physician orders;

7.Every order given by telephone shall be received by an RN or LPN and shall be recorded immediately with the ordering physician's name, and shall be reviewed and signed by a physician within twenty-four (24) hours. Specific to the ordering of medication, documentation shall demonstrate evidence that an order was made by telephone, the content of order, and date of the order;

8.Documentation by the physician of the individual's response to care, including rationale for changes in orders or levels of observation;

9.An IRP which specifies individualized interventions responsive to the needs of the individual;

10.There shall be documentation of consent by the legal guardian to the IRP;

11.Documentation of implementation of interventions, including the individual's response to the interventions;

12.Location and type of treatment or education provided, including the date and time of the treatment or education, the name and credentials of the professional or other staff providing the service, and the response of the individual to the service;

13.Evidence of progress toward stabilization and recovery, or lack thereof;

14.Documentation of medical testing (if any), medical findings and medical care needs or interventions provided;

15.Documentation of continued stay justifications;

16.Documentation at least once per day by an RN as to the status of the individual;

17.Documentation of events or incidents that affect care and treatment, including the individual's response thereto;

18.Record of implementation of emergency safety interventions (seclusion or restraint) of last resort, if implemented;

19.Name and title of staff providing care and treatment; and

20.Discharge notes and aftercare plans, including the individual's status at discharge, ongoing needs, aftercare plan, and the date, time and method of discharge.