R03-608 Discharge Documentation

A. A licensee shall document that the discharge plan is photo copied and provided to the client upon discharge, if possible.

B. A licensee shall ensure that the information necessary to complete the discharge summary:

1. Begins at admission,

2. Includes recommendations and referrals developed with the participation of the client,

3. Evaluates progress with treatment plan goals, and

4. Is entered in the client record within 30 days of completion of treatment.

Review client file to verify discharge plans are completed within 30 days after discharge and contains elements 1 through 3.