Pennsylvania Code
Title 55 - HUMAN SERVICES
Part VI - Mental Health/Intellectual Disability/Autism Manual
Subpart C - Administration and Fiscal Management
Chapter 4210 - DESCRIPTION OF SERVICES AND SERVICE AREAS
RECORDS
Section 4210.122 - Patient records and reports
Universal Citation: 55 PA Code ยง 4210.122
Current through Register Vol. 54, No. 44, November 2, 2024
(a) For administrative and epidemiological purposes, the base service unit shall maintain a central file for each patient in its area. This record will include as a minimum:
(1) A history of all movement of the patient
through services provided directly by the base service unit as well as all
other services provided to him through the county program.
(2) Brief progress notes prepared as services
are provided reporting the status of the patient's treatment either by the base
service unit or by other providers of service.
(b) All of this required information is contained in the following five reports:
(1)
Monthly Contract Report.
(2)
Service Rendered Report.
(3)
Authorization for Service.
(4)
Intake and Proposed Service Plan.
(5) Prescription and Pharmacist
Invoice.
(c) Details on the preparation and distribution of these forms are contained in a separate manual, Patient Service Accountability System.
(d) In addition the base service unit shall maintain a confidential clinical case record file for each patient under treatment by its own staff.
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