Section 2450.62. Case records

(a) Current case records shall be maintained on individuals furnished rehabilitation teaching evaluation services or rehabilitation teaching instructional and follow-up services. Previous information deemed appropriate to the provision of evaluation or instruction shall be included in the current case record.

(b) The complete record of a case closed from rehabilitation teaching services includes but is not limited to the documents and completed forms as follows:

(1) Application and Referral for Service, Form OB-1. Along with the form related correspondence and request for rehabilitation teaching services with justification must be included.

(2) Written documentation by an ophthalmologist or optometrist. A written documentation clearly indicating client’s visual acuity eligibility as defined in the term ‘‘blindness, legal,’’ in § 2450.2 (relating to definitions). In instances of total and irreversible blindness, a written statement by the rehabilitation teacher or other qualified worker is acceptable.

(3) Medical and psychological records. If there is an indication that, in addition to blindness, the applicant has a physical or mental disability which would contraindicate provision of rehabilitation teaching services, in whole or in part, a statement shall be obtained from a qualified physician indicating the limits on activity imposed by the disability.

(4) Rehabilitation teaching evaluation report. See § 2450.72 (relating to evaluation report.)

(5) Rehabilitation teaching progress reports.

(6) Rehabilitation teaching case closure report, as described in § 2450.102 (relating to Rehabilitation Teaching Case Closure Report, Form OB-515).

Notation

Cross References

This section cited in 55 Pa. Code § 2450.101 (relating to evaluation).