Cal. Code Regs. Tit. 22, § 73439 - Special Program Requirements-Patient Health Records
(a) The facility shall assure that every patient receiving special program services shall have an individual record which includes all of the following:
(1) A list of the patients' problems or needs, as identified from the individual assessment.
(2) The behavioral objectives for resolving problems or meeting needs of the patient. These objectives shall be measurable, observable, within time frames and subject to frequent review and updating.
(3) A statement of the plans for how the behavioral objectives will be met. The plans shall include, but not be limited to, all of the following:
(A) Resources to be used
(B) Frequency of plan review and updating
(C) Persons responsible for carrying out plans
(4) Progress notes written by all members of the staff providing program services to the patient. The notes shall be:
(A) Specific to the needs or problems of the patients
(B) Specific to the patient's program objectives and plans.
(5) A summary of the progress of the patient in the project, appropriateness of program objectives, the success or failure of the plans, and any other pertinent information regarding the patient's program shall be available at the time of the patient's reassessment.
Notes
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