# Minn. Stat. § 245I.08: DOCUMENTATION STANDARDS > Minnesota · Statutes · In force URL: https://www.frixlaw.com/law-library/statutes/STATE_MN_P245_267_C245I_S245I.08 ## Section - **Citation:** Minn. Stat. § 245I.08 - **Heading:** DOCUMENTATION STANDARDS - **Jurisdiction:** Minnesota - **Kind:** Statutes - **Status:** In force - **Text as of:** August 14, 2026 - **Source:** Compiled text - **Location:** MN Code / Part 245_267 / Chapter 245I / Section 245I.08 ## Text § Subdivision 1. Generally. A license holder must ensure that all documentation required by this chapter complies with this section. § Subd. 2. Documentation standards. A license holder must ensure that all documentation required by this chapter: (1) is legible; (2) identifies the applicable client name on each page of the client file and staff person name on each page of the personnel file; and (3) is signed and dated by the staff persons who provided services to the client or completed the documentation, including the staff persons' credentials. § Subd. 3. Documenting approval. A license holder must ensure that all diagnostic assessments, functional assessments, level of care assessments, and treatment plans completed by a clinical trainee or behavioral health practitioner contain documentation of approval by a treatment supervisor within ten business days of initial completion by the staff person under treatment supervision. § Subd. 4. Progress notes. A license holder must use a progress note to document each occurrence of a mental health service that a staff person provides to a client. A progress note must include the following: (1) the type of service; (2) the date of service; (3) the start and stop time of the service unless the license holder is licensed as a residential program; (4) the location of the service; (5) the scope of the service, including: (i) the targeted goal and objective; (ii) the intervention that the staff person provided to the client and the methods that the staff person used; (iii) the client's response to the intervention; and (iv) the staff person's plan to take future actions, including changes in treatment that the staff person will implement if the intervention was ineffective; (6) the signature and credentials of the staff person who provided the service to the client; (7) the mental health provider travel documentation required by section 256B.0625 , if applicable; and (8) significant observations by the staff person, if applicable, including: (i) the client's current risk factors; (ii) emergency interventions by staff persons; (iii) consultations with or referrals to other professionals, family, or significant others; and (iv) changes in the client's mental or physical symptoms. § Subd. 5. Medication administration record. If a license holder administers or observes a client self-administer medications, the license holder must maintain a medication administration record for each client that contains the following, as applicable: (1) the client's date of birth; (2) the client's allergies; (3) all medication orders for the client, including client-specific orders for over-the-counter medications and approved condition-specific protocols; (4) the name of each ordered medication, date of each medication's expiration, each medication's dosage frequency, method of administration, and time; (5) the licensed prescriber's name and telephone number; (6) the date of initiation; (7) the signature, printed name, and credentials of the staff person who administered the medication or observed the client self-administer the medication; and (8) the reason that the license holder did not administer the client's prescribed medication or observe the client self-administer the client's prescribed medication. ## Nearby sections - [Minn. Stat. § 245I.01 § 245I.01 PURPOSE AND CITATION.](https://www.frixlaw.com/law-library/statutes/STATE_MN_P245_267_C245I_S245I.01.md) - [Minn. Stat. § 245I.02 § 245I.02 DEFINITIONS.](https://www.frixlaw.com/law-library/statutes/STATE_MN_P245_267_C245I_S245I.02.md) - [Minn. Stat. § 245I.03 § 245I.03 REQUIRED POLICIES AND PROCEDURES.](https://www.frixlaw.com/law-library/statutes/STATE_MN_P245_267_C245I_S245I.03.md) - [Minn. Stat. § 245I.04 § 245I.04 PROVIDER QUALIFICATIONS AND SCOPE OF PRACTICE.](https://www.frixlaw.com/law-library/statutes/STATE_MN_P245_267_C245I_S245I.04.md) - [Minn. Stat. § 245I.05 § 245I.05 TRAINING REQUIRED.](https://www.frixlaw.com/law-library/statutes/STATE_MN_P245_267_C245I_S245I.05.md) - [Minn. Stat. § 245I.06 § 245I.06 TREATMENT SUPERVISION.](https://www.frixlaw.com/law-library/statutes/STATE_MN_P245_267_C245I_S245I.06.md) - [Minn. Stat. § 245I.07 § 245I.07 PERSONNEL FILES.](https://www.frixlaw.com/law-library/statutes/STATE_MN_P245_267_C245I_S245I.07.md) - [Minn. Stat. § 245I.08 § 245I.08 DOCUMENTATION STANDARDS.](https://www.frixlaw.com/law-library/statutes/STATE_MN_P245_267_C245I_S245I.08.md) - [Minn. Stat. § 245I.09 § 245I.09 CLIENT FILES.](https://www.frixlaw.com/law-library/statutes/STATE_MN_P245_267_C245I_S245I.09.md) - [Minn. Stat. § 245I.10 § 245I.10 ASSESSMENT AND TREATMENT PLANNING.](https://www.frixlaw.com/law-library/statutes/STATE_MN_P245_267_C245I_S245I.10.md) - [Minn. Stat. § 245I.11 § 245I.11 HEALTH SERVICES AND MEDICATIONS.](https://www.frixlaw.com/law-library/statutes/STATE_MN_P245_267_C245I_S245I.11.md) - [Minn. Stat. § 245I.011 § 245I.011 APPLICABILITY.](https://www.frixlaw.com/law-library/statutes/STATE_MN_P245_267_C245I_S245I.011.md) - [Minn. Stat. § 245I.12 § 245I.12 CLIENT RIGHTS AND PROTECTIONS.](https://www.frixlaw.com/law-library/statutes/STATE_MN_P245_267_C245I_S245I.12.md) - [Minn. Stat. § 245I.13 § 245I.13 CRITICAL INCIDENTS.](https://www.frixlaw.com/law-library/statutes/STATE_MN_P245_267_C245I_S245I.13.md) --- Source: Frix Law Library, https://www.frixlaw.com/law-library/statutes/STATE_MN_P245_267_C245I_S245I.08. Check the current official text before relying on it. Not legal advice.