PDFWAC 388-101D-0355
What must a client record contain if the client is prescribed a psychotropic medication?
(1) If the client is prescribed psychotropic medication, the client's record must contain:
(a) The date the client met with the prescriber;
(b) Whether the provider was present when the prescriber examined the client;
(c) Any medical or behavioral information the provider conveyed to the prescriber;
(d) Any instructions the provider received from the prescriber;
(e) The drug information sheet obtained from the prescriber or dispensing pharmacy for the psychotropic medication prescribed;
(f) The date the provider sent the client's legal representative a copy of the psychotropic drug information sheet, if requested; and
(g) Any documentation required under WAC 388-101D-0340.
(2) If the provider does not attend the appointment, the provider must document in the client record whether the client attended the appointment independently or with a third party.
(3) The provider must report to the prescriber if:
(a) The medication does not appear to have the prescriber's intended effects; or
(b) Any changes in the client's behavior or health might be an adverse side effect of the medication.
[Statutory Authority: RCW 71A.12.030 and 71A.12.120. WSR 21-12-061, § 388-101D-0355, filed 5/27/21, effective 6/27/21. WSR 16-14-058, recodified as § 388-101D-0355, filed 6/30/16, effective 8/1/16. Statutory Authority: Chapter 71A.12 RCW. WSR 08-02-022, § 388-101-3750, filed 12/21/07, effective 2/1/08.]