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WAC 388-71-0744

What are the center's requirements for client records?

(1) The adult day center must follow their policies and procedures to ensure that the client's record/chart is appropriately organized and that confidentiality of information is maintained.
(2) Client information forms must be standardized, with each page showing the client's name or identification number.
(3) Individual client files must include:
(a) Personal/biographical data, including addresses, phone numbers, emergency contacts, and client representatives, reviewed and updated as needed;
(b) Application, enrollment, and consent to services forms;
(c) Department-authorized service plan and service authorization;
(d) All client information, including but not limited to the intake evaluation, date of acceptance to the center, negotiated care plan, attendance and service records, progress notes, and correspondence;
(e) Signed authorizations concerning the release of client information, photographs, and receipt of emergency medical care, as appropriate;
(f) Client photograph, with client or client representative permission, updated as needed per change in the client's appearances or picture being difficult to clearly view;
(g) Transportation plans regarding how the client will be transported back and forth from the center and who is responsible for the transportation;
(h) Fee determination forms;
(i) Appropriate medical information, with client consent, including but not limited to significant illnesses, accidents, treatments, medical conditions, allergies, medications, tobacco use, and alcohol or substance use;
(j) Advance directives (if any) and a statement signed by the client that he or she has received the center's policies concerning advance directives; and, as applicable;
(k) Authorizing practitioner orders for skilled nursing and/or rehabilitative therapy containing department-required information and in accordance with applicable licensing and practice act regulations.
[Statutory Authority: RCW 74.08.090, 74.09.520. WSR 15-01-174, § 388-71-0744, filed 12/23/14, effective 1/23/15. Statutory Authority: RCW 74.04.050, 74.04.057, 74.04.200, 74.08.090, 74.09.520, and 74.39A.030. WSR 03-06-024, § 388-71-0744, filed 2/24/03, effective 7/1/03.]
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