Section 0940-05-33-.06 - RECIPIENT RECORDS REQUIREMENTS(1) The individual record for each service recipient must also contain the following information: (a) Progress notes which must include written documentation of progress and changes that have occurred within the plan of care and, at a minimum, are documented daily. Progress notes must be dated and minimally include the signature, with title or degree, of the person preparing the note.(b) A discharge summary which includes primary diagnosis, secondary diagnosis (when appropriate), clinical summary, condition at time of discharge or transfer, and aftercare arrangements and recommendations.(c) Results of assessments required by 0940-5-33-.05(d) Individual Plan of Care(e) Standardized diagnostic formulation(s) including, but not limited to, the current Diagnostic and Statistical Manual (DSM) and/or ICD-9.Tenn. Comp. R. & Regs. 0940-05-33-.06
Original rule filed December 18, 2002; effective March 3, 2003.Authority: T.C.A. §§ 4-4-103, 4-5-202, 4-5-204, 33-1-302, 33-1-305, 33-1-309, 33-2-301, and 33-2-302.