309-018-0150 Service Record (1) 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. (2) All providers shall develop and maintain a Service Record for each individual. The record shall, at a minimum, include: (a) Identifying information or documentation of attempts to obtain the information, including: (A) The individual's first and last name, preferred name, address, telephone number, date of birth, sex, gender identity, and for adults, marital status, and military status; (B) First and last name,, address, and telephone number of the parent or legal guardian, primary care giver or emergency contact; and (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) 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; (f) 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; (g) 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; (h) Copies of documents relating to guardianship or any other legal considerations, as applicable; (i) 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; (j) Documentation of any safety risks; (k) Documentation of follow-up actions and referrals when an individual reports symptoms indicating risk of suicide; and (l) Critical Incidents shall be reported to the Division through submission of an incident report and as applicable, to the Office of Training Investigation and Safety (OTIS), and other authorities: (A) In at least the following examples of circumstances: (i) Death, including by suicide or overdose; (ii) Severe injury, overdose resulting in hospitalization or needing medical attention, and emergency services needed; (iii) Ongoing risk to health (for example: environmental risks such as certain molds that pose risks to health); (iv) Police involvement; (v) Extensive damage to the facility or other substantial change in living conditions; and (vi) Where abuse or neglect is suspected, including unethical client and staff relationships; and (vii) Relationships between individuals that result in harm to at least one individual or that are sexual in nature. (B) Within 24 hours of the event; (C) On the original, unredacted incident report; (D) All incident reports shall be maintained in the corresponding service record and in a common file for quality improvement purposes and review by the Division; and (E) In accordance with privacy rules and regulations, incident reports filed in service records shall not contain protected health information belonging to any other individual. (3) Incident reports shall contain, at a minimum, the following information: (a) The time and date of the event; (b) The time and date of when the incident report form was completed; (c) Name and title of staff who filled out the report; (d) Identification of all staff involved in the incident and the response to the incident, and their titles; (e) Identification of each individual involved; (f) Description of event; (g) Description of program response; (h) Description of which policies and procedures were followed and when appliable, any that were not followed; (i) Identification of staff who were notified, and their titles; (j) Identification of which authorities the event was reported to; and (k) Description of administrative response and follow-up. (4) When medical services are provided by the program or a community provider, the following documents shall be part of the Service Record as applicable: (a) Medication administration records as per these rules; (b) Laboratory reports; (c) LMP orders for medication, protocols or procedures; and (d) Documentation of medical screenings, assessments, consultations, interventions, and procedures. Statutory/Other Authority: ORS 413.042, 428.205 - 428.270, 430.640 & 443.450 Statutes/Other Implemented: ORS 430.010, 430.205 - 430.210, 430.254 - 430.640, 430.850 - 430.955, 443.400 - 443.460, 443.991, 461.549 & 743A.168 History: BHS 25-2024, amend filed 10/25/2024, effective 10/27/2024 BHS 10-2024, temporary amend filed 05/21/2024, effective 05/21/2024 through 10/27/2024 BHS 8-2024, temporary amend filed 04/30/2024, effective 05/01/2024 through 10/27/2024 BHS 10-2023, amend filed 04/07/2023, effective 04/07/2023 MHS 4-2018, amend filed 02/27/2018, effective 03/01/2018 MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18 MHS 3-2014, f. & cert. ef. 2-3-14 MHS 10-2013(Temp), f. 8-8-13, cert. ef. 8-9-13 thru 2-5-14