10A N.C. Admin. Code 26D.0902

Current through Register Vol. 39, No. 9, November 1, 2024

Section 26D .0902 - ADMISSION ASSESSMENT

(a) An admission note shall be completed within 24 hours of admission which includes, but need not be limited to:

(1) reason for admission;

(2) present condition of the client reported in objective, behavioral terms, and when possible, a description of the client's condition by others;

(3) diagnostic impression, including a provisional or admitting diagnosis;

(4) determination of and request for additional referrals or special diagnostic tests, assessments or evaluations, if needed; and

(5) a preliminary individual treatment or habilitation plan.

(b) If clinically indicated, a social, educational, medical, criminal, vocational, developmental, and psychiatric history shall be completed within 30 days after admission.

10A N.C. Admin. Code 26D .0902

Authority G.S. 148-19(d);
Eff. January 4, 1994;
Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. June 20, 2015.

Authority G.S. 148-19(d);
Eff. January 4, 1994.