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Wash. Admin. Code § 388-805-325

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Content of Chemical Dependency Service Providers Patient Records

Service providers must ensure that all patient records include patient demographic data, a chemical dependency assessment and history of involvement with alcohol and other drugs, documentation of the patient’s response when asked if the patient is under either court order or Department of Corrections supervision, documentation that the patient was informed of confidentiality requirements and diagnostic assessments,  voluntary consent to treatment, treatment plans, weekly individualized documentation of ongoing services, any medication or lab reports, patient correspondence, tuberculosis test results, documentation of HIV/AIDS risk intervention, and the discharge summary.

Current as of June 2015