Section 2380.173. Content of records  


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  • Each individual’s record must include the following information:

    (1) Personal information including:

    (i) The name, sex, admission date, birthdate and social security number.

    (ii) The race, height, weight, color of hair, color of eyes and identifying marks.

    (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual’s natural home, if other than English.

    (iv) Religious affiliation.

    (v) A current, dated photograph.

    (2) Unusual incident reports related to the individual.

    (3) Physical examinations.

    (4) Assessments as required under § 2380.181 (relating to assessment).

    (5) A copy of the invitation to:

    (i) The initial ISP meeting.

    (ii) The annual update meeting.

    (iii) The ISP revision meeting.

    (6) A copy of the signature sheet for:

    (i) The initial ISP meeting.

    (ii) The annual update meeting.

    (iii) The ISP revision meeting.

    (7) A copy of the current ISP.

    (8) Documentation of ISP reviews and revisions under § 2380.186 (relating to ISP review and revision), including the following:

    (i) ISP review signature sheets.

    (ii) Recommendations to revise the ISP.

    (iii) ISP revisions.

    (iv) Notices that the plan team member may decline the ISP review documentation.

    (v) Requests from plan team members to not receive the ISP review documentation.

    (9) Content discrepancies in the ISP, the annual update or revision under § 2380.186.

    (10) Restrictive procedure protocols and records related to the individual.

    (11) Copies of psychological evaluations, if applicable.

The provisions of this § 2380.173 adopted January 15, 1993, effective January 16, 1993, 23 Pa.B. 343; amended August 27, 2010, effective August 28, 2010, 40 Pa.B. 4935. Immediately preceding text appears at serial page (259702).

Notation

Authority

The provisions of this § 2380.173 amended under sections 911 and 1021 of the Public Welfare Code (62 P. S. § § 911 and 1021).

Cross References

This section cited in 55 Pa. Code § 2380.174 (relating to record location).