OAR 309-018-0150
Service Record

(1) Documentation shall be appropriate in quality and quantity to meet professional standards applicable to the provider and any additional standards for documentation in the provider’s policies and any pertinent contracts.

(2) All providers shall develop and maintain a Service Record for each individual upon entry. The record shall, at a minimum, include:

(a) Identifying information or documentation of attempts to obtain the information, including:

(A) The individual’s name, address, telephone number, date of birth, gender, and for adults, marital status and military status;

(B) Name, address, and telephone number of the parent or legal guardian, primary care giver or emergency contact; and

(b) Informed Consent for Service including medications or documentation specifying why the provider could not obtain consent by the individual or guardian as applicable;

(d) A signed fee agreement, when applicable;

(e) Assessment and updates to the assessment;

(f) A service plan;

(g) Service notes;

(h) Transfer documentation;

(i) Other plans as made available, such as but not limited to recovery plans, wellness action plans, education plans, and advance directives for physical and mental health care;

(j) Applicable signed consents for release of information;

(k) A personal belongings inventory created upon entry and updated whenever an item of significant value is added or removed or on the date of transfer;

(L) Documentation indicating that the individual and guardian, as applicable, were provided with the required orientation information upon entry;

(m) Background information including strengths and interests, all available previous mental health or substance use assessments, previous living arrangements, service history, behavior support considerations, education service plans if applicable, and family and other support resources;

(n) Medical information including a brief history of any health conditions, documentation from a LMP or other qualified health care professional of the individual’s current physical health, and a written record of any prescribed or recommended medications, services, dietary specifications, and aids to physical functioning;

(o) Copies of documents relating to guardianship or any other legal considerations, as applicable;

(p) A copy of the individual’s most recent service plan, if applicable, or in the case of an emergency or crisis-respite entry, a summary of current substance use or mental health services;

(q) Documentation of the individual’s ability to evacuate the home consistent with the program’s evacuation plan developed in accordance with the Oregon Structural Specialty Code and Oregon Fire Code;

(r) Documentation of any safety risks;

(s) Documentation of follow-up actions and referrals when an individual reports symptoms indicating risk of suicide; and

(t) Incident reports.

(3) When medical services are provided, the following documents shall be part of the Service Record as applicable:

(a) Medication administration records as per these rules;

(b) Laboratory reports; and

Source: Rule 309-018-0150 — Service Record, https://secure.sos.state.or.us/oard/view.action?ruleNumber=309-018-0150.

California:	Codes
Colorado:	C.R.S.
Nevada:	NRS
New York:	Laws
Oregon:	OAR, ORS
Texas:	Statutes
World:	Rome Statute, International Dictionary

OAR 309-018-0150 Service Record

OAR 309-018-0150
Service Record