Indiana Administrative Code
Title 460 - DIVISION OF DISABILITY AND REHABILITATIVE SERVICES
Article 6 - SUPPORTED LIVING SERVICES AND SUPPORTS
Rule 17 - Maintenance of Records of Services Provided
Section 17-4 - Individual's personal file; provider's office

Universal Citation: 460 IN Admin Code 17-4

Current through July 10, 2024

Authority: IC 12-9-2-3; IC 12-11-1.1-9; IC 12-11-2.1-12

Affected: IC 12-11-1.1; IC 12-11-2.1

Sec. 4.

(a) A provider specified in the individual's ISP as being responsible for maintaining the individual's personal file shall maintain a personal file for an individual at the provider's office.

(b) The individual's personal file shall contain documentation of the following:

(1) A change in an individual's physical condition or mental status.

(2) An unusual event for the individual.

(3) All health and medical services provided to an individual.

(4) An individual's training outcomes.

(c) A change or unusual event referred to in subsection (b) shall include the following:

(1) Vomiting.

(2) Choking.

(3) Falling.

(4) Disorientation or confusion.

(5) Patterns of behavior.

(6) A seizure.

(d) The documentation of a change or an event referred to in subsections (b) and (c) shall include the following:

(1) The date, time, and duration of the change or event.

(2) A description of the response of the provider, or the provider's employees or agents to the change or event.

(3) The signature of the provider or the provider's employees or agents observing the change or event.

(e) The documentation of all health and medical services provided to the individual shall:

(1) be kept chronologically; and

(2) include the following:
(A) Date of services provided to the individual.

(B) A description of services provided.

(C) The signature of the health care professional providing the services.

(f) The individual's training file shall include documentation regarding the individual's training goals required by 460 IAC 6-24-1.

Disclaimer: These regulations may not be the most recent version. Indiana may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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