Section 709.93. Client records  


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  • (a) There shall be a complete client record on an individual which includes information relative to the client’s involvement with the project. This shall include, but not be limited to, the following:

    (1) Consent forms.

    (2) Medication records.

    (3) Record of services provided.

    (4) Referral contact.

    (5) Progress notes.

    (6) Individual treatment and rehabilitation plan.

    (7) Client-related correspondence.

    (8) Case consultation notes.

    (9) Aftercare plan, if applicable.

    (10) Discharge summary.

    (11) Follow-up information.

    (b) The project shall develop and maintain client records on standardized project client record forms.