37.106.2137    PROGRAM DOCUMENTATION

(1) Data relative to accomplishment of the criteria specified in client individual treatment plan objectives must be documented in measurable terms.

(2) The facility must document significant events that are related to the client's individual treatment plan and assessments and that contribute to an overall understanding of the client's ongoing level and quality of functioning.

(3) The facility staff must prepare progress notes which indicate whether or not the stated individual treatment plan has been implemented, and the degree to which the client is progressing, or failing to progress, toward stated treatment objectives. The progress notes must be entered into the client's clinical record at least weekly and upon the occurrence of any significant change in the client's condition.

History: Sec. 50-5-103 and 50-5-238, MCA; IMP, Sec. 53-5-103, 50-5-201 and 50-5-238, MCA; NEW, 2003 MAR p. 1322, Eff. 7/1/03.