Ariz. Admin. Code § R9-10-308 - Treatment Plan
A. Except for a
patient admitted to receive crisis services or as provided in
R9-10-315(E) or
(F), an administrator shall ensure that a
treatment plan is developed and implemented for a patient that:
1. Is based on the behavioral health
assessment and on-going changes to the behavioral health assessment of the
patient;
2. Is completed:
a. By a behavioral health professional or by
a behavioral health technician under the clinical oversight of a behavioral
health professional, and
b. Before
the patient receives treatment;
3. Is documented in the patient's medical
record within 24 hours after the patient first receives treatment;
4. Includes:
c.
d. The signature of the patient or the patient's
representative and date signed, or documentation of the refusal to
sign;
d.
e. The date when the patient's treatment plan will be
reviewed;
e.
f. If a discharge date has been determined, the
treatment needed after discharge; and
f.
g. The signature of the
personnel member who developed the treatment plan and the date
signed;
a. The patient's presenting issue, including
the acuity of the patient's presenting issue;
b. The behavioral health services and
physical health services to be provided to the patient;
c. If the patient was admitted after a
suicide attempt or who exhibits suicidal ideation:
i. The results of the suicide assessment
required in
R9-10-307(11),
and
ii. Information specific to
helping prevent a recurrence;
5. If the
treatment plan was completed by a behavioral health technician, is reviewed and
signed by a behavioral health professional within 24 hours after the completion
of the treatment plan to ensure that the treatment plan identifies the acuity
of the patient and meets the patient's treatment needs; and
6. Is reviewed and updated on an on-going
basis:
a. According to the review date
specified in the treatment plan,
b.
When a treatment goal is accomplished or changes,
c. When additional information that affects
the patient's behavioral health assessment is identified, and
d. When a patient has a significant change in
condition or experiences an event that affects treatment.
B. An administrator shall ensure
that:
1. A request for participation in
developing a patient's treatment plan is made to the patient or the patient's
representative;
2. An opportunity
for participation in developing the patient's treatment plan is provided to the
patient or the patient's representative; and
3. The request in subsection (B)(1) and the
opportunity in subsection (B)(2) are documented in the patient's medical
record.
C. If a patient
who is admitted to receive crisis services remains admitted as a patient after
the patient no longer needs crisis services, an administrator shall ensure that
a treatment plan for the patient is:
1. Except
for subsection (A)(3), completed according to the requirements in subsection
(A); and
2. Documented in the
patient's medical record within 24 hours after the patient no longer needs
crisis services.
Notes
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