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 E - STANDARDS FOR INPATIENT NONHOSPITAL ACTIVITIES-RESIDENTIAL TREATMENT AND REHABILITATION
Section 709.53 - Client records

Universal Citation: 28 PA Code § 709.53

Current through Register Vol. 54, No. 44, November 2, 2024

(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) Individualized treatment and rehabilitation plan.

(7) Client-related correspondence.

(8) Case consultation notes.

(9) Aftercare plan, if applicable.

(10) Discharge summary.

(11) Follow-up information.

(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.

(13) Documentation of special dietetic needs, if applicable.

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

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