Section 460IAC6-17-4. Individual's personal file; provider's office

   (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 an individual at the provider's office.

  (b) The individual's personal file shall contain documentation of the following:

(1) A change in an individual's physical condition or mental status.

(2) An unusual event for the individual.

(3) All health and medical services provided to an individual.

(4) An individual's training outcomes.

  (c) A change or unusual event referred to in subsection (b) shall include the following:

(1) Vomiting.

(2) Choking.

(3) Falling.

(4) Disorientation or confusion.

(5) Patterns of behavior.

(6) A seizure.

  (d) The documentation of a change or an event referred to in subsections (b) and (c) shall include the following:

(1) The date, time, and duration of the change or event.

(2) A description of the response of the provider, or the provider's employees or agents to the change or event.

(3) The signature of the provider or the provider's employees or agents observing the change or event.

  (e) The documentation of all health and medical services provided to the individual shall:

(1) be kept chronologically; and

(2) include the following:

(A) Date of services provided to the individual.

(B) A description of services provided.

(C) The signature of the health care professional providing the services.

  (f) The individual's training file shall include documentation regarding the individual's training goals required by 460 IAC 6-24-1. (Division of Disability and Rehabilitative Services; 460 IAC 6-17-4; filed Nov 4, 2002, 12:04 p.m.: 26 IR 774; filed Aug 29, 2003, 10:30 a.m.: 27 IR 112; readopted filed Sep 26, 2008, 11:11 a.m.: 20081015-IR-460080618RFA; readopted filed Aug 11, 2014, 11:20 a.m.: 20140910-IR-460140241RFA)