Alabama Administrative Code › Title 420 - ALABAMA STATE BOARD OF HEALTH › Chapter 420-5-7 - HOSPITALS › Section 420-5-7-.26 - Psychiatric Hospitals

Current through Register Vol. 42, No. 9, June 28, 2024
(1) A
			 psychiatric hospital, or an inpatient psychiatric program within a hospital
			 that is not a psychiatric hospital, shall be primarily engaged in providing, by
			 or under the supervision of a doctor of medicine or osteopathy, psychiatric
			 services for the diagnosis and treatment of mentally ill persons.
(2) Special medical record requirements.
(a) The medical records maintained by a
			 psychiatric hospital shall permit determination of the degree and intensity of
			 the treatment provided to individuals who are furnished services in the
			 institution.
(b) Development of
			 assessment and diagnostic data. Medical records shall stress the psychiatric
			 components of the record, including history of findings and treatment provided
			 for the psychiatric condition for which the patient is hospitalized.
1. The identification data shall include the
			 circumstances under which the patient was admitted and/or is being treated -
			 i.e., voluntary, involuntary, committed by court, evaluation and
			 recertification.
2. A provisional
			 or admitting diagnosis shall be made on every patient at the time of admission,
			 and shall include the diagnoses of intercurrent diseases as well as the
			 psychiatric diagnoses.
3. The
			 reasons for admission shall be clearly documented as stated by the patient
			 and/or others significantly involved.
4. The social service records, including
			 reports of interviews with patients, family members, and others, shall provide
			 an assessment of home plans and family attitudes, and community resource
			 contacts as well as a social history.
5. When indicated, a complete neurological
			 examination shall be recorded at the time of the admission physical
			 examination.
(c)
			 Psychiatric evaluation. Each patient shall receive a psychiatric evaluation
			 that shall:
1. Be completed within 60 hours
			 of admission;
2. Include a medical
			 history;
3. Contain a record of
			 mental status;
4. Note the onset of
			 illness and the circumstances leading to admission;
5. Describe attitudes and behavior;
6. Estimate intellectual functioning, memory
			 functioning, and orientation; and
7. Include an inventory of the patient's
			 assets in descriptive, not interpretative, fashion.
(d) Treatment plan.
1. Each patient shall have an individual
			 comprehensive treatment plan that shall be based on an inventory of the
			 patient's strengths and disabilities.
(i) The
			 written plan shall include:
(I) A
			 substantiated diagnosis;
(II)
			 Short-term and long-range goals;
(III) The specific treatment modalities
			 utilized;
(IV) The responsibilities
			 of each member of the treatment team; and
(V) Adequate documentation to justify the
			 diagnosis and the treatment and rehabilitation activities carried
			 out.
(ii) The treatment
			 received by the patient shall be documented in such a way to assure that all
			 active therapeutic efforts are included.
(e) Recording progress. Progress notes shall
			 be recorded by the doctor of medicine or osteopathy responsible for the care of
			 the patient, nurse, social worker and, when appropriate, others significantly
			 involved in active treatment modalities. The frequency of progress notes is
			 determined by the condition of the patient but shall be recorded at least
			 weekly for the first two months and at least once a month thereafter and shall
			 contain recommendations for revisions in the treatment plan as indicated as
			 well as precise assessment of the patient's progress in accordance with the
			 original or revised treatment plan.
(f) Discharge planning and discharge summary.
			 The record of each patient who has been discharged shall have a discharge
			 summary that includes a recapitulation of the patient's hospitalization and
			 recommendations from appropriate services concerning follow-up or aftercare as
			 well as a brief summary of the patient's condition on discharge.