Pennsylvania Code
Title 55 - HUMAN SERVICES
Part VII - Mental Health Manual
Subpart D - Nonresidential Agencies/Facilities/Services
Chapter 5230 - PSYCHIATRIC REHABILITATION SERVICES
INDIVIDUAL RECORD
Section 5230.21 - Content of individual record
Universal Citation: 55 PA Code ยง 5230.21
Current through Register Vol. 54, No. 44, November 2, 2024
A PRS agency shall develop and maintain a record for an individual served containing the following:
(1) Information that identifies the individual.
(2) Eligibility for PRS, including diagnosis.
(3) Referral source, reason for referral and recommendation by an LPHA.
(4) A signed set of documents providing the following:
(i) Individual consent to receive
services.
(ii) Individual consent
to release information to other providers.
(iii) Verification that the individual
received and had an opportunity to discuss the oral and written versions of the
PRS statement of rights under §
5230.41 (relating to PRS statement
of rights).
(5) An assessment and updates.
(6) The IRP.
(7) Staff documentation of IRP outcomes.
(8) Staff documentation of coordination with other services and supports.
(9) Discharge summary.
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