048-6 Wyo. Code R. § 6-1
The program shall maintain a written clinical record on each client. These records shall serve the dual purpose of providing information useful to program personnel and documentation necessary to satisfy the accountability requirements of authorized funding sources. Each record shall contain:
(a) Client identifying data that is recorded on the state MIS forms.
(b) A clinical assessment, including a diagnosis or diagnostic impression.
(c) Documentation that clients have been informed of their rights.
(d) A record of the consent of the client, or legally responsible other, for the clients treatment.
(e) A fee agreement signed by the client or legally responsible other.
(f) An individualized treatment plan based on the clinical assessment, including the services and strategies to be used to meet identified treatment goals.
(g) Periodic documentation of client progress in achieving treatment goals, including updates of individualized treatment plans as frequently as clinically indicated.
(h) A discharge summary written within 90 days of a clients last clinical contact containing a summary of pertinent case record information including referrals to other continuing care services.
(i) Dated and signed clinical entries, including the clinical degree or title of the staff member.
(j) Other pertinent documentation as applicable, including but not limited to medications prescribed by a physician affiliated with the program and written interpretation of testing.
(k) Clinical entries made in clinical records by persons who are not qualified to act as a primary therapist under these Standards must be countersigned by the clinical supervisor.
048-6 Wyo. Code R. § 6-1