Pennsylvania Code
Title 28 - HEALTH AND SAFETY
Part V - Department of Drug and Alcohol Programs
Chapter 709 - STANDARDS FOR LICENSURE OF FREESTANDING TREATMENT FACILITIES
Subchapter D - STANDARDS FOR INTAKE, EVALUATION AND REFERRAL ACTIVITIES
Section 709.44 - Client records
Universal Citation: 28 PA Code ยง 709.44
Current through Register Vol. 54, No. 12, March 23, 2024
(a) The project shall maintain a client record on an individual which shall include, but not be limited to:
(1) Histories, which include the
following:
(i) Medical history.
(ii) Drug or alcohol history, or
both.
(iii) Personal
history.
(2) Consent
forms.
(3) Psychosocial
evaluation.
(4) Referral
contact.
(5) Record of services
provided.
(b) If applicable, the project shall also include the following items in the client record:
(1) Results of physical
examination.
(2) Medication
records.
(3) Treatment and
rehabilitation plans.
(4) Follow-up
information.
(c) The project shall develop and maintain client records on standardized project client record forms.
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