§ 73423. Special Rehabilitation Program Services -Patient Health Records.

(a) The facility shall insure that every patient receiving special program services shall have an individual record which includes all of the following:

(1) A list of the patient's problems or needs, as identified from the individual assessment.

(2) The behavioral objectives for resolving problems or meeting needs of the patient. These objectives shall be measurable, observable, within time frames and subject to frequent review and updating.

(3) A statement of the plan for how the behavioral objectives will be met. The statement shall include, but not be limited to all of the following:

(A) Resources to be used.

(B) Frequency of plan review and updating.

(C) Persons responsible for carrying out plans.

(4) The progress notes written by all members of the staff providing program services to the patient. The notes shall be:

(A) Specific to the needs or problems of the patients.

(B) Specific to the patient's program objectives and plans.

(5) A summary of the progress of the patient in the program, the appropriateness of program objectives, the success or failure of the plan and any other pertinent information regarding the patient's program shall be available at the time of the patient's reassessment.