Pennsylvania Code (Last Updated: April 5, 2016) |
Title 55. PUBLIC WELFARE |
PART VII. Mental Health Manual |
Subpart D. Nonresidential Agencies/Facilities/Services |
Chapter 5230. Psychiatric Rehabilitation Services |
Section 5230.63. Daily entry
Latest version.
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A PRS agency shall include an entry for the day service was provided in the record of an individual as follows:
(1) Indicates the date, time, duration, location and type of interaction.
(2) Documents service provided in the context of the goal.
(3) Documents the individual response to service.
(4) Includes the signature of the individual, or if the individual does not sign, documents the reason.
(5) Is signed and dated by staff providing the service.