Section 2390.124. Content of records

Each client’s record must include the following information:

(1) The name, sex, admission date, birthdate and place, social security number and dates of entry, transfer and discharge.

(2) The name, address and telephone number of parents, legal guardian and a designated person to be contacted in case of an emergency.

(3) The name and telephone number of a physician or source of health care.

(4) Written consent from the client, parent or guardian for emergency medical treatment.

(5) Physical examinations.

(6) Assessments as required under § 2390.151 (relating to assessment).

(7) A copy of the vocational evaluations, if applicable.

(8) A copy of the invitation to:

(i) The initial ISP meeting.

(ii) The annual update meeting.

(iii) The ISP revision meeting.

(9) A copy of the signature sheet for:

(i) The initial ISP meeting.

(ii) The annual update meeting.

(iii) The ISP revision meeting.

(10) A copy of the current ISP.

(11) Documentation of ISP reviews and ISP revisions under § 2390.156 (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.

(12) Content discrepancy in the ISP, the annual update or revision under § 2390.156.

(13) Restrictive procedure protocols and records related to the client.

(14) Unusual incident reports related to the client.

(15) Copies of psychological evaluations, if applicable.

(16) Vocational evaluations as required under § 2390.159 (relating to vocational evaluation).

The provisions of this § 2390.124 adopted May 9, 1986, effective August 8, 1986, 16 Pa.B. 1693; amended August 27, 2010, effective August 28, 2010, 40 Pa.B. 4935. Immediately preceding text appears at serial page (259743).

Notation

Authority

The provisions of this § 2390.124 amended under sections 911 and 1021 of the Public Welfare Code (62 P. S. § § 911 and 1021).