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 I. STANDARDS FOR OUTPATIENT ACTIVITIES |
Section 709.93. Client records
Latest version.
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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) 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.