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 I - STANDARDS FOR OUTPATIENT ACTIVITIES
Section 709.93 - Client records
Universal Citation: 28 PA Code ยง 709.93
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) 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.
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