10a NCAC 26d .0902 ADMISSION ASSESSMENT
(a) An admission note shall be completed within 24 hours of admission which includes, but need not be limited to:
(1) reason for admission;
(2) present condition of the client reported in objective, behavioral terms, and when possible, a description of the client's condition by others;
(3) diagnostic impression, including a provisional or admitting diagnosis;
(4) determination of and request for additional referrals or special diagnostic tests, assessments or evaluations, if needed; and
(5) a preliminary individual treatment or habilitation plan.
(b) If clinically indicated, a social, educational, medical, criminal, vocational, developmental, and psychiatric history shall be completed within 30 days after admission.
History Note: Authority G.S. 148‑19(d);
Eff. January 4, 1994;
Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. June 20, 2015.