---
kind: "section"
citation: "42 C.F.R. § 456.180"
title: "42"
number: "456.180"
heading: "Individual written plan of care."
url: "https://uscodex.org/cfr/42/456.180"
---

# §456.180. Individual written plan of care.

- (a) Before admission to a mental hospital or before authorization for payment, the attending physician or staff physician must establish a written plan of care for each applicant or beneficiary.
- (b) The plan of care must include—
  - (1) Diagnoses, symptoms, complaints, and complications indicating the need for admission;
  - (2) A description of the functional level of the individual;
  - (3) Objectives;
  - (4) **Any orders for—**
    - (i) Medications;
    - (ii) Treatments;
    - (iii) Restorative and rehabilitative services;
    - (iv) Activities;
    - (v) Therapies;
    - (vi) Social services;
    - (vii) Diet; and
    - (viii) Special procedures recommended for the health and safety of the patient;
  - (5) Plans for continuing care, including review and modification to the plan of care; and
  - (6) **Plans for discharge.**
- (c) The attending or staff physician and other personnel involved in the beneficiary's care must review each plan of care at least every 90 days.

## Notes

### Authority

Authority: 42 U.S.C. 1302.

### Source

Source: 43 FR 45266, Sept. 29, 1978, unless otherwise noted.