PN1 Progress notes shall contain: the date and time the session ended: the purpose of the session; topics discussed; client behavior and response to the treatment provided during the session; significant events; and the name, signature and title of the staff person conducting the session.

PN2 Group and individual treatment sessions progress shall be documented per session.

PN3 Outpatient treatment is documented per session.

PN4 Partial day treatment notes contain information required by but may be compressed into a single note that addresses treatment provided on a per day basis.

PN5 Residential treatment shall be documented at least daily.

PN6 The client's progress in meeting treatment plan goals will be assessed at the time of discharge.

PN7 Significant client events that fall within the provisions of the “Incident Reporting Policy” shall be documented as soon as possible after the event. The administration of first aid to a client shall be documented as soon as possible. Any client behavior that could lead to a disciplinary action shall be documented as soon as possible. Any other event, that could effect the client's treatment, shall be documented as soon as possible.

PN8 When a client refuses to divulge information and/or follow the recommended course of treatment, this refusal is noted in the case client record.

PN9 When a client transfers from one program to another, the transferring program shall send copies of the transferring client's records to the licensed receiving program prior to admission.