309-022-0145 Service Record (1) All providers shall develop and maintain a service record for each individual upon entry. (2) Documentation shall be appropriate in quality and quantity to meet professional standards applicable to the provider and any additional standards for documentation in the provider’s policies and any pertinent contracts. (3) The service record shall, at a minimum, include: (a) Identifying information or documentation of attempts to obtain the information, including: (A) The individual's name, address, telephone number, date of birth, and gender; (B) Name, address, and telephone number of the parent or legal guardian, primary care giver, or emergency contact; (C) Contact information for medical and dental providers. (b) Informed Consent for Service, including medications or documentation specifying why the provider could not obtain consent by the individual or guardian as applicable; (c) Written refusal of any services and supports offered, including medications; (d) A signed fee agreement, when applicable; (e) Assessment and updates to the assessment; (f) A service plan, including any applicable behavior support or crisis intervention planning; (g) Service notes; (h) A transfer summary, when applicable; (i) Applicable signed consents for release of information. (4) When medical services are provided, the following documents shall be part of the service record as applicable: (a) Medication administration records; (b) Laboratory reports; and (c) LMP orders for medication, protocols, or procedures. (5) Providers shall maintain additional service record documentation as follows: (a) A personal belongings inventory created upon entry and updated whenever an item of significant value is added or removed or on the date of transfer; (b) Documentation indicating that the individual and guardian, as applicable, were provided with the required orientation information upon entry; (c) Background information including strengths and interests, all available previous mental health or substance use assessments, previous living arrangements, service history, behavior support considerations, education service plans if applicable, and family and other support resources; (d) Medical information including a brief history of any health conditions, documentation from a LMP or other qualified health care professional of the individual's current physical health, and a written record of any prescribed or recommended medications, services, dietary specifications, and aids to physical functioning; (e) Copies of documents relating to guardianship or any other legal considerations, as applicable; (f) A copy of the individual’s most recent service plan, if applicable, or in the case of an emergency or crisis-respite entry, a summary of current addictions or mental health services and any applicable behavior support plans; (g) Documentation of the individual’s ability to evacuate the home consistent with the program’s evacuation plan developed in accordance with the Oregon Structural Specialty Code and Oregon Fire Code; (h) Documentation of any safety risks; (i) Incident reports, when required, including: (A) The date of the incident, the persons involved, the details of the incident, and the quality and performance actions taken to initiate investigation of the incident and correct any identified deficiencies; and (B) Any child abuse reports made by the provider to law enforcement or to the Department’s Child Welfare Programs documenting the date of the incident, the individuals involved and, if known, the outcome of the reports. (j) Level of service intensity determination; (k) Names and contact information of the members of the interdisciplinary team; (L) Documentation by the interdisciplinary team that the child's service plan has been reviewed, the services provided are medically appropriate for the specific level of care, and changes in the plan recommended by the interdisciplinary team, as indicated by the child's service and support needs, have been implemented; (m) Emergency safety intervention records in a separate section or in a separate format documenting each incident of personal restraint or seclusion, signed and dated by the qualified program staff directing the intervention and, if required, by the psychiatrist or clinical supervisor authorizing the intervention; and (n) A copy of the written transition instructions provided to the child and family on the date of transfer. Statutory/Other Authority: ORS 161.390, 413.042, 430.256, 426.490 - 426.500, 428.205 - 428.270, 430.640 & 443.450 Statutes/Other Implemented: ORS 109.675, 161.390 - 161.400, 179.505, 413.520 - 413.522, 426.380 - 426.395, 426.490 - 426.500, 430.010, 430.205 - 430.210, 430.240 - 430.640, 430.850 - 430.955, 443.400 - 443.460, 443.991 & 743A.168 History: BHS 24-2018, amend filed 12/27/2018, effective 01/25/2019 BHS 16-2018, temporary amend filed 07/17/2018, effective 08/01/2018 through 01/27/2019 MHS 5-2014, f. & cert. ef. 2-3-14 MHS 8-2013(Temp), f. 8-8-13, cert. ef. 8-9-13 thru 2-5-14