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.