10a NCAC 26d .0905       PROGRESS NOTES

(a)  Progress notes shall be recorded at least on a weekly basis in residential and inpatient services and following each scheduled appointment in outpatient services.

(b)  Progress notes shall reflect the client's progress or lack of progress:

(1)           in meeting goals;

(2)           in staff interventions;

(3)           regarding information which may have a significant impact on the client's condition; and

(4)           when indicating reviews of relevant laboratory reports and actions taken.

 

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.