Pennsylvania Code (Last Updated: April 5, 2016) |
Title 28. HEALTH AND SAFETY |
PART V. Department of Drug and Alcohol Programs |
Chapter 709. Standards for Licensure of Freestanding Treatment Facilities |
SubChapter H. STANDARDS FOR PARTIAL HOSPITALIZATION ACTIVITIES |
Section 709.83. Client records
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(a) There shall be a complete client record on an individual which includes information relative to the clients involvement with the project. This shall include, but not be limited to the following:
(1) Consent forms.
(2) Treatment and rehabilitation plan.
(3) Client-related correspondence.
(4) Case consultation notes.
(5) Medication records.
(6) Aftercare plans, if applicable.
(7) Referral contact.
(8) Record of services provided.
(9) Progress notes.
(10) Discharge summary.
(11) Follow-up information.
(12) Verification that work done by the client at the project is an integral part of the treatment and rehabilitation plan.
(b) The project shall develop and maintain client records on standardized project client record forms.