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The form is mandatory for various programs including Crisis Stabilization Unit (CSU), Detox Level III, CSS, Intensive Residential Treatment Program (IRTP), and Respite.
All documentation must connect to specific goals outlined in the Individualized Action Plan (IAP).
Essential identifying information includes the person's name, record number, date of birth, and organization name.
Staff must document any new issues presented by the person during their shift, with options for resolution or further assessment.
The form requires recording specific goals and objectives addressed during the shift/day as per the IAP.
Providers must assess and document the person's response to interventions and progress towards goals and objectives.
The form includes detailed instructions for completing a billing strip, including date of service, provider number, location code, and diagnostic code.