Current through Register Vol. 63, No. 12, December 1, 2024
(1) All
providers shall develop and maintain a service record for each individual upon
entry.
(2) Documentation shall be
appropriate in quality and quantity to meet professional standards applicable
to the provider and any additional standards for documentation in the
provider's policies and any pertinent contracts.
(3) The service record shall, at a minimum,
include:
(a) Identifying information or
documentation of attempts to obtain the information, including:
(A) The individual's name, address, telephone
number, date of birth, and gender;
(B) Name, address, and telephone number of
the parent or legal guardian, primary care giver, or emergency
contact;
(C) Contact information
for medical and dental providers.
(b) Informed Consent for Service, including
medications or documentation specifying why the provider could not obtain
consent by the individual or guardian as applicable;
(c) Written refusal of any services and
supports offered, including medications;
(d) A signed fee agreement, when
applicable;
(e) Assessment and
updates to the assessment;
(f) A
service plan, including any applicable behavior support or crisis intervention
planning;
(h) A transfer summary, when
applicable;
(i) Applicable signed
consents for release of information.
(4) When medical services are provided, the
following documents shall be part of the service record as applicable:
(a) Medication administration
records;
(b) Laboratory reports;
and
(c) LMP orders for medication,
protocols, or procedures.
(5) Providers shall maintain additional
service record documentation as follows:
(a)
A personal belongings inventory created upon entry and updated whenever an item
of significant value is added or removed or on the date of transfer;
(b) Documentation indicating that the
individual and guardian, as applicable, were provided with the required
orientation information upon entry;
(c) Background information including
strengths and interests, all available previous mental health or substance use
assessments, previous living arrangements, service history, behavior support
considerations, education service plans if applicable, and family and other
support resources;
(d) Medical
information including a brief history of any health conditions, documentation
from a LMP or other qualified health care professional of the individual's
current physical health, and a written record of any prescribed or recommended
medications, services, dietary specifications, and aids to physical
functioning;
(e) Copies of
documents relating to guardianship or any other legal considerations, as
applicable;
(f) A copy of the
individual's most recent service plan, if applicable, or in the case of an
emergency or crisis-respite entry, a summary of current addictions or mental
health services and any applicable behavior support plans;
(g) Documentation of the individual's ability
to evacuate the home consistent with the program's evacuation plan developed in
accordance with the Oregon Structural Specialty Code and Oregon Fire
Code;
(h) Documentation of any
safety risks;
(i) Incident reports,
when required, including:
(A) The date of the
incident, the persons involved, the details of the incident, and the quality
and performance actions taken to initiate investigation of the incident and
correct any identified deficiencies; and
(B) Any child abuse reports made by the
provider to law enforcement or to the Department's Child Welfare Programs
documenting the date of the incident, the individuals involved and, if known,
the outcome of the reports.
(j) Level of service intensity
determination;
(k) Names and
contact information of the members of the interdisciplinary team;
(I) Documentation by the interdisciplinary
team that the child's service plan has been reviewed, the services provided are
medically appropriate for the specific level of care, and changes in the plan
recommended by the interdisciplinary team, as indicated by the child's service
and support needs, have been implemented;
(m) Emergency safety intervention records in
a separate section or in a separate format documenting each incident of
personal restraint or seclusion, signed and dated by the qualified program
staff directing the intervention and, if required, by the psychiatrist or
clinical supervisor authorizing the intervention; and
(n) A copy of the written transition
instructions provided to the child and family on the date of
transfer.
Statutory/Other Authority: ORS
161.390,
413.042,
430.256,
426.490 -
426.500,
428.205 -
428.270,
430.640 &
443.450
Statutes/Other Implemented: ORS
109.675,
161.390 -
161.400,
179.505,
413.520 -
413.522,
426.380 -
426.395,
426.490 -
426.500,
430.010,
430.205 -
430.210,
430.240 -
430.640,
430.850 -
430.955,
443.400 -
443.460,
443.991 &
743A.168
