OAR 309-073-0055: Temporary rule language in effect until 09/15/2026. Service Record

(1) The Crisis Stabilization Center must include the following documentation in the individual's service record: (a) Presenting problem and referral source, if applicable. (b) Rationale for denial of services and referral of the individual to other appropriate services, if necessary. (c) Status as a current or former member of the U.S. Armed Forces. (d) Current mental health and substance use symptoms. (e) Current medications. (f) Screening for suicide risk and completion of a comprehensive, standardized suicide risk assessment and planning, when clinically indicated. (g) Screening for risk of violence and completion of a comprehensive, standardized violence risk assessment and planning, when clinically indicated. (h) Screening for substance use disorder and referral for substance use disorder services when appropriate. (i) Current trauma-related symptoms or concerns for personal safety. (j) Screening for food and housing insecurity. (k) Crisis Stabilization Plan; and (l) Discharge information including: (A) Outcome of the services provided. (B) Services provided. (C) Care coordination efforts. (D) Referrals; and (E) Follow-up efforts including attempts to contact within 72 hours from discharge. (2) If an individual’s ability to cooperate and communicate with program staff due to their crisis situation prevents the completion of any of the items in subsection (1), it must be clearly documented in the individual’s service record.