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 5230.22 - Documentation standards and record security, retention and disposal
Universal Citation: 55 PA Code ยง 5230.22
Current through Register Vol. 54, No. 44, November 2, 2024
A PRS agency shall ensure that an individual record meets the following standards:
(1) The record must be legible throughout.
(2) The record must identify the individual on each page.
(3) Entries shall be signed and dated by the responsible staff.
(4) The record must indicate progress at each day of service, changes in service and response to services.
(5) Updates of the record shall be signed and dated.
(6) The record is kept in a permanent, secure location.
(7) The record shall be maintained for a minimum of 4 years.
(8) Records shall be disposed of in a manner that protects confidentiality.
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