Rule 5122-27-05 | Treatment summary.
(A) When the provider determines the client is no longer active a treatment summary is to be completed within thirty days. This means the documentation should be finalized and included in the client record within that time frame.
(B) The treatment summary is to include all of the following information:
(1) The client's date of admission.
(2) The date of the client's last receipt of certifiable services or supports from the provider.
(3) The outcome of the service or support provided (i.e., amount of progress or the level of care).
(4) The client's final diagnosis.
(5) The client's American society of addiction medicine (ASAM) third edition level of care at the time of admission and discharge, if applicable.
(6) Any recommendations the provider made to the client associated with the client's comprehensive individualized treatment plan, including recommendations for where to seek crisis care or emergency services or referrals to other community resources.
(7) Medications the provider prescribed to the client upon the client's termination of services or supports.
(8) If the provider terminated the client from services or supports on an involuntary basis, documentation that the provider informed the client of the right to appeal.
(9) The signature and credentials of the provider staff member who prepared the treatment summary with the date of the staff member's signature. For purposes of this subparagraph, a signature may be handwritten or in any of the following forms:
(a) A code consisting of a combination of letters, numbers, characters, or symbols that is adopted or executed by an individual as that individual's electronic signature;
(b) A computer-generated signature code created for an individual; or
(c) An electronic image of an individual's handwritten signature created by using a pen computer.
Last updated August 3, 2026 at 8:37 AM
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