ARSD 67:61:17:05. Monitoring and documentation of client's condition

The clinically-managed, residential detoxification program shall establish a policy and procedure concerning the steps staff shall take when assessing and monitoring a client's physical condition and responding to medical complications throughout the detoxification process.

Staff shall closely monitor the condition of each client during detoxification and document the following information in the client's case record:

(1) Blood pressure, pulse, and respiration:

(a) At admission;

(b) At least two times in the first eight hours after admission and at a greater frequency depending on the degree of the client's hypertension or hypotension; and

(c) At least once every eight hours thereafter;

(2) Physical, mental, and emotional state, including presence of confusion, anxiety, depression, hallucinations, restlessness, sleep disturbances, tremors, ataxia, or excessive perspiration; and

(3) Type and amount of fluid intake.

Any staff member who assesses, monitors, or responds to a client's condition, must be trained to perform those functions.