PDFWAC 388-101D-0385
Contents of client records.
(1) Crisis diversion service providers are exempt from the client record requirements specified in this section.
(2) Service providers must keep, in each client's record, information including but not limited to the following:
(a) Client's name, address, and Social Security number;
(b) Name, address, and telephone number of the client's involved family members, guardian or legal representative;
(c) Copies of legal guardianship papers, if provided;
(d) Client health records, including:
(i) Name, address, and telephone number of the client's physician, dentist, mental health service provider, and any other current health care service provider;
(ii) Current health care service providers' instructions about health care needed, including appointment dates and date of next appointment if appropriate;
(iii) Written documentation that the health care service providers' instructions have been followed; and
(iv) Record of major health events and surgeries when known.
(e) Copy of the client's most recent individual support plan;
(f) Client's individual instruction and support plan including:
(i) Instruction and support activities for each client as a basis for review and evaluation of client's progress;
(ii) Semiannual review of the individual instruction and support plan;
(iii) Consultation with other service providers and other interested persons;
(iv) Individual instruction and support plan revisions and changes; and
(v) Other activities relevant to the client that the client wants included.
(g) Progress notes and incident reports;
(h) The client's financial records for funds managed by the service provider, including:
(i) Receipts, ledgers and records of the client's financial transactions; and
(ii) Client's related bankbooks, checkbooks, bank registers, tax records and bank statements.
(i) Burial plans and wills.
[WSR 16-14-058, recodified as § 388-101D-0385, filed 6/30/16, effective 8/1/16. Statutory Authority: Chapter 71A.12 RCW. WSR 08-02-022, § 388-101-3810, filed 12/21/07, effective 2/1/08.]