Section 250.2290  Special Medical Record Requirements for Psychiatric Hospitals and Psychiatric Units of General Hospitals or General Hospitals Providing Psychiatric Care

Medical records shall emphasize the psychiatric components of the patient's condition and care, including history of findings and treatment rendered for the psychiatric condition for which the patient is hospitalized.

a)         Identification data shall include the patient's personal and medical history, as available.

b)         A provisional or admitting diagnosis shall be made on every patient at the time of admission and include the diagnoses of intercurrent diseases as well as the psychiatric diagnoses.

c)         Data from all pertinent sources shall be included in addition to data obtained from the patient.

d)         The psychiatric evaluation shall comply with 42 CFR 482.61.

e)         A complete neurological examination shall be recorded at the time of the admission physical examination, when indicated.

f)         The social service records, including reports of interviews with patients, family members and others, shall provide an assessment of home plans and family attitudes, and community resource contacts with appropriate recommendations for family and community resource involvement, as well as a social history.

g)         Reports of consultations, including reports of electroencephalograms and other pertinent reports of special studies, shall be included in the record.

h)         The patient's comprehensive treatment plan shall be recorded, based on an inventory of the patient's strengths as well as the patient's disabilities, and shall include:

1)         A substantiated diagnosis in the terminology of the American Psychiatric Association's Diagnostic and Statistical Manual, (DSM-5-TR);

2)         Short-term and long-range goals and the specific treatment modalities utilized; and

3)         The responsibilities of each member of the treatment team in a manner that provides adequate justification and documentation for the diagnoses and for the treatment and rehabilitation activities carried out.

i)          The treatment received by the patient shall be documented in a manner and with enough frequency to assure that all active therapeutic efforts, such as individual and group psychotherapy, drug therapy, milieu therapy, occupational therapy, recreational therapy, industrial or work therapy, nursing care, and other therapeutic interventions, are included.

j)          Progress notes shall be recorded by the physician, clinical psychologist, nurse, social worker and by others directly involved in active treatment modalities.  The notes shall contain recommendations for revisions in the treatment plan as indicated as well as a precise assessment of the patient's progress in accordance with the original or revised treatment plan.

k)         The discharge summary shall include a recapitulation of the patient's hospitalization and recommendations from appropriate services concerning follow-up or aftercare as well as a brief summary of the patient's condition on discharge.

l)          The unique confidentiality requirements of a psychiatric record shall be recognized and safeguarded in any unitized record keeping system of a general hospital, as required by Section 250.1510.

(Source:  Amended at 50 Ill. Reg. 8128, effective May 26, 2026)