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PDFWAC 246-341-0640

ClinicalAdditional record content.

Each agency licensed by the department to provide any behavioral health service is responsible for an individual's clinical record content. The clinical record must include:
(1) Documentation the individual received a copy of counselor disclosure requirements as required for the counselor's credential;
(2) Demographic information;
(3) An assessment;
(4) Documentation of the individual's response when asked if:
(a) The individual is under department of corrections (DOC) supervision;
(b) The individual is under civil or criminal court ordered mental health or substance use disorder treatment; and
(c) There is a court order exempting the individual participant from reporting requirements. A copy of the court order must be included in the record if the participant claims exemption from reporting requirements.
(5) Documentation that the agency is in compliance with RCW 71.05.445 regarding mental health services for individuals under department of corrections supervision;
(6) Documentation the individual was informed of applicable federal and state confidentiality requirements;
(7) Documentation of confidential information that has been released without the consent of the individual under:
(a) RCW 70.02.050;
(b) The Health Insurance Portability and Accountability Act (HIPAA); and
(c) RCW 70.02.230 and 70.02.240 if the individual received mental health treatment services.
(8) Documentation that any mandatory reporting of abuse, neglect, or exploitation consistent with chapters 26.44 and 74.34 RCW has occurred;
(9) If treatment is not court-ordered, documentation of informed consent to treatment by the individual or individual's parent, or other legal representative;
(10) If treatment is court-ordered, a copy of the order;
(11) Medication records, if applicable;
(12) Laboratory reports, if applicable;
(13) Properly completed authorizations for release of information, if applicable;
(14) Copies of applicable correspondence;
(15) Discharge information as follows:
(a) A discharge statement if the individual left without notice;
(b) Discharge information for an individual who did not leave without notice, completed within seven working days of the individual's discharge, including:
(i) The date of discharge;
(ii) Continuing care plan;
(iii) Legal status, and if applicable; and
(iv) Current prescribed medication.
(c) When an individual is transferring to another service provider, documentation that copies of documents pertinent to the individual's course of treatment were forwarded to the new service provider with the individual's permission.
(16) A copy of any report required by entities such as the courts, department of corrections, department of licensing, and the department of health, and the date the report was submitted;
(17) Progress notes must include the date, time, duration, participant's name, response to interventions, and a brief summary of the session and the name and credential of the staff member who provided it;
(18) Documentation of coordination with any systems or organizations the individual identifies as being relevant to treatment, with the individual's consent or if applicable, the consent of the individual's parent or legal representation; and
(19) A crisis plan, if one has been developed.
[Statutory Authority: 2018 c 201 and 2018 c 291. WSR 19-09-062, § 246-341-0640, filed 4/16/19, effective 5/17/19.]
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