Section 388-877A-0120. Outpatient mental health services—Clinical record content and documentation.

In addition to meeting the general clinical record content requirements in WAC 388-877-0640, an agency providing any outpatient mental health service is responsible for an individual's clinical record. The clinical record must document:

(1) That the agency requested a copy of and placed in the record, if provided, the following:

(a) Discharge summaries and/or evaluations resulting from outpatient or inpatient mental health services received within the last five years, if available; and

(b) Any crisis plan that has been developed.

(2) Any previously accessed inpatient or outpatient services and/or medications to treat a mental health condition.

(3) That services were provided by, or under the clinical supervision of, a mental health professional.

(4) Any clinical consultation and/or evaluation provided.

(5) Progress notes in a timely manner and before any subsequent scheduled appointments of the same type of service session or group type, or documentation as to why this did not occur. Progress notes must include the date, time, duration, participant names, and a brief summary of the session and the name of the staff member who provided it.

(6) That the individual was provided with information and education about the individual's mental illness.

(7) Any referrals to other services and supports, including referrals to treatment for co-occurring disorders and health care.

(8) That with the individual's consent, the individual's self-identified family members and significant others were provided with information and education about the individual's mental illness.

(9) That the additional requirements for any optional outpatient services the agency providers are met.

(10) That staff members met with the individual at the time of discharge, unless the individual left without notice, to:

(a) Determine the appropriate recommendation for care and finalize a continuing care plan;

(b) Assist the individual in making contact with necessary agencies or services; and

(c) Provide and document the individual was provided with a copy of the plan.

(11) That a discharge summary was completed within seven working days of the individual's discharge. The discharge plan must include the date of discharge, continuing care plan, legal status, and if applicable, current prescribed medication.

[Statutory Authority: Chapters 70.02, 70.96A, 71.05, 71.24, 71.34, 74.50 RCW, RCW 74.08.090, 43.20A.890, and 42 C.F.R. Part 8. WSR 13-12-053, § 388-877A-0120, filed 5/31/13, effective 7/1/13.]

Chapters 70.02, 70.96A, 71.05, 71.24, 71.34, 74.50 RCW, RCW 74.08.090, 43.20A.890, and 42 C.F.R. Part 8. WSR 13-12-053, § 388-877A-0120, filed 5/31/13, effective 7/1/13.

Rules

388-877-0640,