21 NCAC 30 .0504             DOCUMENTATION; REFERRALS

The licensee shall:

(1)           maintain documentation for each session, including the date of service, needs assessment, plan of care, observations made, and actions taken by the licensee;

(2)           refer the client to other health care practitioners or other professional service providers when the referral is in the best interest of the client or licensee;

(3)           follow recommendations for the plan of care when receiving a client referral from a medical care provider. Questions or concerns regarding the referrals shall be directed to the referring medical provider.

History Note:        Authority G.S. 90-626(9);

Temporary Adoption Eff. February 15, 2000;

Eff. April 1, 2001;

Amended Eff. September 2, 2005;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. November 12, 2014;

Amended Eff. April 1, 2017.