Section 460IAC6-17-3. Individual's personal file; site of service delivery

   (a) A provider specified in the individual's ISP as being responsible for maintaining the individual's personal file shall maintain a personal file for the individual at:

(1) the individual's residence; or

(2) the primary location where the individual receives services.

  (b) The individual's personal file shall contain at least the following information:

(1) The individual's full name.

(2) Telephone numbers for emergency services that may be required by the individual.

(3) A current sheet with a brief summary regarding:

(A) the individual's diagnosis or diagnoses;

(B) the individual's treatment protocols, current medications, and other health information specified by the individual's ISP;

(C) behavioral information about the individual;

(D) likes and dislikes of the individual that have been identified in the individual's ISP; and

(E) other information relevant to working with the individual.

(4) The individual's history of allergies, if applicable.

(5) Consent by the individual or the individual's legal representative for emergency treatment for the individual.

(6) A photograph of the individual, if:

(A) a photograph is available; and

(B) inclusion of a photograph in the individual's file is specified by the individual's ISP.

(7) A copy of the individual's current ISP.

(8) A copy of the individual's behavioral support plan, if applicable.

(9) Documentation of:

(A) changes in the individual's physical condition or mental status during the last sixty (60) days;

(B) an unusual event such as vomiting, choking, falling, disorientation or confusion, behavioral problems, or seizures occurring during the last sixty (60) days; and

(C) the response of each provider to the observed change or unusual event.

(10) If an individual's outcomes include bill paying and other financial matters, the individual's file shall contain:

(A) the individual's checkbook with clear documentation that the checkbook has been balanced; and

(B) bank statements with clear documentation that the bank statements and the individual's checkbook have been reconciled.

(11) All environmental assessments conducted during the last sixty (60) days, with the signature of the person or persons conducting the assessment on the assessment.

(12) All medication administration documentation for the last sixty (60) days.

(13) All seizure management documentation for the last sixty (60) days.

(14) Health-related incident management documentation for the last sixty (60) days.

(15) All nutritional counseling services documentation for the last sixty (60) days.

(16) All behavioral support services documentation for the last sixty (60) days.

(17) All outcome directed documentation for the last sixty (60) days.

(Division of Disability and Rehabilitative Services; 460 IAC 6-17-3; filed Nov 4, 2002, 12:04 p.m.: 26 IR 774; filed Aug 29, 2003, 10:30 a.m.: 27 IR 111; readopted filed Sep 26, 2008, 11:11 a.m.: 20081015-IR-460080618RFA; readopted filed Aug 11, 2014, 11:20 a.m.: 20140910-IR-460140241RFA)