Washington Administrative Code › Title 246 - Health, Department of › FACILITY STANDARDS AND LICENSING › Chapter 246-341 - Behavioral health agency licensing and certification requirements › BEHAVIORAL HEALTH-GENERAL REQUIREMENTS › Section 246-341-0640 - Individual service record content

Current through Register Vol. 24-14, July 15, 2024
A behavioral health agency is responsible for the
					 components and documentation in an individual's individual service record
					 content unless specified otherwise in certification or individual service
					 requirements.
(1) The individual
				  service record must include:
(a) Documentation
				  the individual received a copy of counselor disclosure requirements as required
				  for the counselor's credential.
(b)
				  Identifying information.
(c) An
				  assessment which is an age-appropriate, strengths-based psychosocial assessment
				  that considers current needs and the individual's relevant behavioral and
				  physical health history according to best practices, completed by a person
				  appropriately credentialed or qualified to provide the type of assessment
				  pertaining to the service(s) being sought, which includes:
(i) Presenting issue(s);
(ii) An assessment of any risk of harm to
				  self and others, including suicide, homicide, and a history of self-harm and,
				  if the assessment indicates there is such a risk, a referral for provision of
				  emergency/crisis services;
(iii)
				  Treatment recommendations or recommendations for additional program-specific
				  assessment;
(iv) A diagnostic
				  assessment statement, including sufficient information to determine a diagnosis
				  supported by the current and applicable
Diagnostic and Statistical
				  Manual of Mental Disorders
(DSM-5)
,
or
Diagnostic Classification of Mental Health and
				  Developmental Disorders of Infancy and Early Childhood
(DC:0-5)
;
(v) A placement decision, using ASAM criteria
				  dimensions, when the assessment indicates the individual is in need of
				  substance use disorder services.
(d) Individual service plan that:
(i) Is completed or approved by a person
				  appropriately credentialed or qualified to provide mental health, substance
				  use, co-occurring, or problem gambling disorder services;
(ii) Addresses issues identified in the
				  assessment and by the individual or, if applicable, the individual's parent(s)
				  or legal representative;
(iii)
				  Contains measurable goals or objectives and interventions;
(iv) Must be mutually agreed upon and updated
				  to address changes in identified needs and achievement of goals or at the
				  request of the individual or, if applicable, the individual's parent or legal
				  representative;
(v) Must be in a
				  terminology that is understandable to the individuals and the individual's
				  family or legal representative, if applicable.
(e) If treatment is not court-ordered,
				  documentation of informed consent to treatment by the individual or
				  individual's parent, or other legal representative.
(f) Progress and group notes including the
				  date, time, duration, participant's name, response to interventions or
				  clinically significant behaviors during the group session, and a brief summary
				  of the individual or group session and the name and credential of the staff
				  member who provided it.
(g) If
				  treatment is for a substance use disorder, documentation that ASAM criteria was
				  used for admission, continued services, referral, and discharge planning and
				  decisions.
(h) Discharge
				  information as follows:
(i) A discharge
				  statement if the individual left without notice; or
(ii) Discharge information for an individual
				  who did not leave without notice, completed within seven working days of the
				  individual's discharge, including:
(A) The
				  date of discharge;
(B) Continuing
				  care plan; and
(C) If applicable,
				  current prescribed medication.