(1) Entries in the client's record must be typewritten or legibly written in ink, dated, and signed by the recording person with his/her title. Identification of the author may be a signature, initials, or other unique identifier within the requirements of applicable licensing standards and center policy.
(2) Progress notes must be chronological, timely, and recorded at least weekly by adult day health centers and at least monthly by adult day care center. Client dates of attendance are to be kept daily.
(3) Consultation and/or care plan reviews must be dated and initialed by the physician or other authorizing practitioner who reviewed them. If the reports are presented electronically, there must be representation of review by the ordering practitioner.
(4) Documentation of medication use must include the name of the medication, dosage, route of administration, site of injection if applicable, and signature or initials of the person administering the medication, title, and date.
(5) The record must be legible to someone other than the writer.
(6) Department-contracted adult day health centers must comply with all other applicable documentation requirements under WAC 388-502-0020
[Statutory Authority: RCW 74.04.050, 74.04.057, 74.04.200, 74.08.090, 74.09.520, and 74.39A.030. 03-06-024, § 388-71-0746, filed 2/24/03, effective 7/1/03.]