Section 460 IAC 6-25-3 - Documentation of health care services received by an individualAuthority: 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. 3.
(a) The provider identified in section 1 of this rule shall maintain a personal file for each individual served.(b) The individual's personal file shall contain the following information: (1) The date of health and medical services provided to the individual.(2) A description of the health care or medical services provided to the individual.(3) The signature of the person providing the health care or medical service for each date a service is provided.(4) Additional information and documentation required in this rule, including documentation of the following:(A) An organized system for medication administration.(B) An individual's refusal to take medication.(C) Monitoring of medication side effects.(E) Changes in an individual's status.(F) An organized system of health-related incident management.(G) If applicable to this provider, an investigation of the death of an individual.Division of Disability and Rehabilitative Services; 460 IAC 6-25-3; filed Nov 4, 2002, 12:04 p.m.: 26 IR 780; readopted filed Sep 26, 2008, 11:11 a.m.: 20081015-IR-460080618RFA; Readopted filed 8/11/2014, 11:20 a.m.: 20140910-IR-460140241RFAReadopted filed 11/9/2020, 3:08 p.m.: 20201209-IR-460200501RFA