10a ncac 27g .3814       DOCUMENTATION REQUIREMENTS

(a)  When conducting the assessment for an individual charged with, or convicted of, offenses related to Driving While Impaired (DWI), a DMH Form 508-R shall be completed.

(b)  If treatment is recommended, client record documentation shall include, but not be limited to the following minimum requirements for each DWI Category of Service listed in Rule .3805 of this Section, except for the ADETS category:

(1)           all items specified in the "clinical interview", as defined in Rule .3805 of this Section;

(2)           results of the administration of an approved "standardized test", as defined in Rule .3805 of this Section;

(3)           release of information as set forth in Rules .3807 and .3810 of this Section; and

(4)           release of information covering any collateral contacts, and documentation of the collateral information.

(c)  Substance abuse facility policies and operational procedures shall be in writing and address and comply with each of the requirements in 10A NCAC 27G .0201.

(d)  Substance abuse treatment records shall comply with the elements contained in 10A NCAC 27G .0203, .0204, .0206 of this Subchapter and 10A NCAC 27G .3807 and 10A NCAC 27G .3810.

 

History Note:        Authority G.S. 20-179 (e)(6) and (m); 122C-142.1; 143B-147;

Eff. April 1, 2001.