S.D. Admin. R. 67:16:41:08

Current through Register Vol. 51, page 67, December 16, 2024

Section 67:16:41:08 - Clinical record requirements

The mental health provider must maintain the recipient's clinical record. In addition to the record requirements contained in chapter 67:16:34, the recipient's clinical record must contain all of the following information, including the related supporting clinical data:

(1) Concise data on client history, including present illness and complaints, past history (psychological, social, and medical), previous hospitalization and treatment, and a drug-use profile;

(2) A diagnostic assessment which meets the requirements of § 67:16:41:04;

(3) A treatment plan which meets the requirements of § 67:16:41:06;

(4) A chronological record of known psychotropic medications prescribed and dispensed;

(5) Documentation of treatment plan reviews required in § 67:16:41:07;

(6) The specific services provided together with the date and amount of time of delivery of each service provided;

(7) The signature or initials and credential of the mental health provider providing the service;

(8) The location of the setting in which the service was provided;

(9) The relationship of the service to the treatment plan objectives and goals;

(10) Progress or treatment notes, entered chronologically at each encounter of service, documenting and summarizing progress the recipient is making during a given period of time toward attaining the treatment objectives and goals; an assessment of the recipient's current symptoms; a report of procedures administered during the session; and a plan for the next treatment session; and

(11) When the treatment is complete or discontinued, a discharge summary which relates to the treatment received and progress made in achieving the treatment goals. A discharge summary is not required when the recipient prematurely discontinues the treatment.

All entries within the required clinical record must be current, consistently organized, legible, signed or initialed, and dated by the mental health provider.

S.D. Admin. R. 67:16:41:08

22 SDR 6, effective 7/26/1995; 46 SDR 050, effective 10/10/2019

General Authority: SDCL 28-6-1(1)(2).

Law Implemented: SDCL 28-6-1(1)(2).