(A) The agency shall document progress or lack of progress toward the achievement of specified treatment outcomes identified on the individualized service plan (ISP). Documentation of progress may be done through use of checklists and/or brief narrative.
(B) Each individual staff providing services shall document progress or lack of progress each day that a service is provided.
The exception shall be the provision of group services, when a minimum of one staff person shall complete the progress note documentation.
(1) When multiple contacts of the same type of service are provided in one day, the staff may complete one progress note per day, rather than per service contact.
(2) When the same staff person provides more than one type of service in the same day to an individual client, e.g. behavioral health counseling and therapy service and community psychiatric supportive treatment service, the staff shall complete a separate progress note for each different type of service provided.
(C) Documentation shall include, at a minimum:
(1) The date of the service contact;
(2) The time of day and duration of each service contact;
(3) The location of each service contact;
(4) A description of the service(s) rendered;
(5) Whether or not the intervention provided is specifically authorized by the service plan that was developed based on a mental health assessment. The exception shall be the following circumstances, in which case the documentation must include the presenting problem in addition to the other requirements of this rule:
(a) Pharmacologic management service provided as the least restrictive alternative prior to completion of a mental health assessment, as described in paragraph (B) of rule 5122-29-04 of the Administrative Code, and
(b) Crisis intervention mental health service when not listed on the treatment plan;
(6) The assessment of the client's progress or lack of progress, and a brief description of progress made, if any;
(7) Significant changes or events in the life of the client, if applicable;
(8) Recommendation for modifications to the ISP, if applicable; and
(9) The signature and credentials, or initials, of the provider of the service and the date of the signature. The credentials are the provider's qualifications to provide the service according to the matrix in Chapter 5122-29 of the Administrative Code. A provider signing a progress note utilizing initials must maintain a signature sheet, including credentials, in the individual client record (ICR).
(D) Documentation in the progress note, or elsewhere in the individual client record, may include a notation that there is no change in the client's risk of harm to self or others, or, if there is a change, the results of a review of the client's ideation, intent, plan, access, and previous attempts.
R.C. 119.032 review dates: 02/15/2015
Promulgated Under: 119.03
Statutory Authority: 5119.61(A) , 5119.611(C)
Rule Amplifies: 5119.61(a) , 5119.611(c)
Prior Effective Dates: 9/4/03