Section 388-877-1142 - Mental health inpatient services-Crisis stabilization unit-Admission, assessment, and records(1) For persons who have been brought to the unit involuntarily by police: (a) The clinical record must contain: (i) A statement of the circumstances under which the person was brought to the unit;(ii) The admission date and time; and(iii) The date and time when the twelve hour involuntary detention period ends; and(b) The evaluation required in subsection (2)(b) of this section must be performed within three hours of arrival at the facility.(2) For all persons, the clinical record must contain:(a) An assessment for substance use disorder and co-occurring mental health and substance abuse disorder, utilizing the global appraisal of individual needs - short screener (GAIN-SS) or its successor;(b) An evaluation by a mental health professional to include at a minimum: (i) Mental status examination;(ii) Assessment of risk of harm to self, others, or property; and(iii) Determination of whether to refer to a designated crisis responder (DCR) to initiate civil commitment proceedings;(c) Documentation that an evaluation by a DCR was performed within the required time period, the results of the evaluation, and the disposition of the person;(d) Review of the person's current crisis plan, if applicable and available;(e) The admission diagnosis and what information the determination was based upon;(f) Assessment and stabilization services provided by the appropriate staff;(g) Coordination with the person's current treatment provider, if applicable; and(h) A plan for discharge, including a plan for follow up that includes: (i) The name, address, and telephone number of the provider of follow-up services; and(ii) The follow up appointment date and time, if known.(3) For persons admitted to the crisis stabilization unit on a voluntary basis, the clinical record must contain a crisis stabilization plan developed collaboratively with the person within twenty-four hours of admission that includes: (a) Strategies and interventions to resolve the crisis in the least restrictive manner possible;(b) Language that is understandable to the person and members of the person's support system; and(c) Measurable goals for progress toward resolving the crisis and returning to an optimal level of functioning.(4) If antipsychotic medications are administered, the clinical record must document: (a) The physician's attempt to obtain informed consent for antipsychotic medication; and(b) The reasons why any antipsychotic medication is administered over the person's objection or lack of consent.Wash. Admin. Code § 388-877-1142
Adopted by WSR 18-06-043, Filed 3/1/2018, effective 4/1/2018