Section 0940-05-37-.06 - RECORD REQUIREMENTS(1) The individual record for each service recipient must contain the following information: (a) Documentation of the POC and the Individualized Education Program (if required) and of their implementation;(b) Progress notes must be recorded daily, and must include written documentation of service recipient progress and changes, which have occurred within the POC. The progress notes must be dated and include the signature, title or degree of the person who provided the service;(c) Documentation of all drugs prescribed and/or administered by the facility which indicates date prescribed, type, dosage, frequency, amount, and reason;(d) Narrative summary review at least every six (6) months of all medications prescribed which includes specific reasons for continuation of each medication;(e) Documentation of significant behavior; and actions taken by staff;(f) A list of each article of the service recipient's personal property valued at one hundred dollars ($100.00) or more, and its disposition if no longer in use;(g) Documentation of abuse, medical problems, accidents, seizures, and illnesses and treatment for such abuse, accidents, seizures, and illnesses, and any reports generated as the result;(h) Results of assessments required by this rule;(i) Discharge summary which states, service recipient's condition at the time of discharge and signature of person preparing the summary.(j) Documentation of an education plan developed for each service recipient that conforms to the Rules, Regulations, and Minimum Standards of the State Board of Education and the Individualized Education Program (IEP) test being developed by an appropriately constituted IEP-Team for all "qualified students with disabilities." The education plan may include education services provided either by the facility or by the local education agency.
(k) Appropriate consents and authorizations for the release and obtaining of information about the service recipient.Tenn. Comp. R. & Regs. 0940-05-37-.06
Original rule filed June 29, 2004; effective September 12, 2004.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, 32-2-302, and 33-2-404.