The community support service provider must maintain a clinical record for each consumer and safeguard the record against loss, defacement, tampering, or use by unauthorized persons. The clinical record must contain:
(1) An intake evaluation;
(2) Evidence that the consumer rights statement was provided to the consumer;
(3) A copy of any advance directives, powers of attorney or letters of guardianship provided by the consumer;
(4) The crisis treatment plan when appropriate;
(5) The individualized service plan and all changes in the plan;
(6) Documentation that services are provided by or under the clinical supervision of a mental health professional;
(7) Documentation that services are provided by, or under the clinical supervision, or the clinical consultation of a mental health specialist. Consultation must occur within thirty days of admission and periodically thereafter as specified by the mental health specialist;
(8) Periodic documentation of the course of treatment and objective progress toward established goals for rehabilitation, recovery and reintegration into the mainstream of social, employment and educational choices;
(9) A notation of extraordinary events affecting the consumer;
(10) Documentation of mandatory reporting of abuse, neglect, or exploitation of consumers consistent with chapters
26.44 and
74.34 RCW;
(11) Documentation that the department of corrections was notified by the provider when a consumer on an less restrictive alternative or department of corrections order mental health treatment informs them that they are under supervision by department of corrections. Notification can be either written or oral. If oral notification, it must be confirmed by a written notice, including e-mail and fax. The disclosure to department of corrections does not require the person's consent;
(12) If the consumer has been given relief by the committing court it must be confirmed in writing;
(13) When the mental health provider becomes aware of a violation that relates to public safety of court ordered treatment of a consumer who is both in a less restrictive alternative and is being supervised by the department of corrections, documentation that an evaluation by a designated mental health professional was requested;
(14) Documentation of informed consent to treatment and medications by the consumer or legally responsible other;
(15) Documentation of confidential information that has been released without the consent of the consumer including, but not limited to provisions in RCW
70.02.050,
71.05.390 and
71.05.630.
[Statutory Authority: RCW 71.24.035, 71.05.560, and chapters 71.24 and 71.05 RCW. 06-17-114, § 388-865-0430, filed 8/18/06, effective 9/18/06. Statutory Authority: RCW 71.05.445 and 71.05.390 as amended by 2004 c 166. 05-14-082, § 388-865-0430, filed 6/30/05, effective 7/31/05. Statutory Authority: RCW 71.05.560, 71.24.035 (5)(c), 71.34.800,9.41.047 , 43.20B.020, and 43.20B.335. 01-12-047, § 388-865-0430, filed 5/31/01, effective 7/1/01.]