Section 460IAC6-25-3. Documentation of health care services received by an individual

   (a) The provider identified in section 1 of this rule shall maintain a personal file for each individual served.

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

(1) The date of health and medical services provided to the individual.

(2) A description of the health care or medical services provided to the individual.

(3) The signature of the person providing the health care or medical service for each date a service is provided.

(4) Additional information and documentation required in this rule, including documentation of the following:

(A) An organized system for medication administration.

(B) An individual's refusal to take medication.

(C) Monitoring of medication side effects.

(D) Seizure tracking.

(E) Changes in an individual's status.

(F) An organized system of health-related incident management.

(G) If applicable to this provider, an investigation of the death of an individual.

(Division of Disability and Rehabilitative Services; 460 IAC 6-25-3; filed Nov 4, 2002, 12:04 p.m.: 26 IR 780; readopted filed Sep 26, 2008, 11:11 a.m.: 20081015-IR-460080618RFA; readopted filed Aug 11, 2014, 11:20 a.m.: 20140910-IR-460140241RFA)