10a NCAC 26d .0906      TRANSFER OR DISCHARGE SUMMARY

(a)  Whenever a client is transferred to a different level of service, a written transfer note by the referring unit shall accompany the client summarizing the client's condition at the time of transfer, and any recommendations for continued care.

(b)  A qualified professional in the receiving unit shall evaluate the client to determine the need for continued treatment or habilitation.

(c)  At the time of discharge, a discharge summary shall be completed and shall include:

(1)           the reason for admission;

(2)           course and progress of the client in relation to the goals and strategies in the individual treatment or habilitation plan;

(3)           condition of the client at discharge;

(4)           recommendations and arrangements for further services or treatment; and

(5)           final diagnosis.

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.