Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 250 - HOSPITAL LICENSING REQUIREMENTS › Subpart S - PSYCHIATRIC SERVICES › Section 250.2290 - Special Medical Record Requirements for Psychiatric Hospitals and Psychiatric Units of General Hospitals or General Hospitals Providing Psychiatric Care

Current through Register Vol. 48, No. 28, July 12, 2024
Medical records must stress the psychiatric components of the
				  patient's condition and care including history of findings and treatment
				  rendered for the psychiatric condition for which the patient is
				  hospitalized.
a) Identification data
				must include the patient's legal status.
b) A provisional or admitting diagnosis must
				be made on every patient at the time of admission and include the diagnoses of
				intercurrent diseases as well as the psychiatric diagnoses.
c) Data from all pertinent sources must be
				included in addition to data obtained from the patient.
d) The psychiatric evaluation, including a
				medical history must contain a record of mental status and note the onset of
				illness, the circumstances leading to admission, attitudes, behavior, estimate
				of intellectual functions, memory functioning, orientation, and an inventory of
				the patient's assets in descriptive, not interpretive, fashion.
e) A complete neurological examination must
				be recorded at the time of the admission physical examination, when
				indicated.
f) The social service
				records, including reports of interviews with patients, family members and
				others, must provide an assessment of home plans and family attitudes, and
				community resource contacts with appropriate recommendations for family and/or
				community resource involvement, as well as a social history.
g) Reports of consultations, reports of
				electroencephalograms and other pertinent reports of special studies must be
				included in the record.
h) The
				patient's comprehensive treatment plan must be recorded, based on an inventory
				of the patient's strengths as well as his disabilities, and must include a
				substantiated diagnosis in the terminology of the American Psychiatric
				Association's Diagnostic and Statistical Manual, (DSM-3), short-term and long
				range goals, and the specific treatment modalities utilized as well as the
				responsibilities of each member of the treatment team in such a manner that it
				provides adequate justification and documentation for the diagnoses and for the
				treatment and rehabilitation activities carried out.
i) The treatment received by the patient must
				be documented in such a manner and with such frequency as to assure that all
				active therapeutic efforts such as individual and group psychotherapy, drug
				therapy, milieu therapy, occupational therapy, recreational therapy, industrial
				or work therapy, nursing care and other therapeutic interventions are
				included.
j) Progress notes must be
				recorded by the physician, clinical psychologist, nurse, social worker and by
				others significantly involved in active treatment modalities. The notes must
				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.
k) The discharge summary must include 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.
l) It is recommended that the unique
				confidentiality requirements of a psychiatric record be recognized and
				safeguarded in any unitized record keeping system of a general
				hospital.