Utah Administrative Code
Topic - Human Services
Title R501 - Human Services Program Licensing
Rule R501-1 - General Provisions for Licensure
Section R501-1-11 - Program Client Record Requirements
Universal Citation: UT Admin Code R 501-1-11
Current through Bulletin 2024-06, March 15, 2024
(1) The licensee shall maintain client information to include the following:
(a)
client name, address, email address, phone number, date of birth and identified
gender;
(b) emergency contact
names, including legal guardian where applicable, and at minimum, the emergency
contact's physical address, current email address or current phone
numbers;
(c) a program serving
substance use disorder clients shall maintain compliance with an initial and
annual client tuberculosis screening results in each client record;
(d) any information that could affect health
safety or well-being of the client including each medication, allergy, chronic
condition or communicable disease;
(e) intake screening and
assessment;
(f) discharge
documentation;
(g) treatment or
service plan;
(h) progress notes
and services provided with date and signature of staff completing each
entry;
(i) individualized
assessment for restriction of access to on-site items that could be used as
weapons, for self-directed violence, or as an intoxicant;
(j) any referral arrangements made by the
program;
(k) client or guardian
signed consent or court order of commitment to services in lieu of signed
consent for each treatment and non-clinical service;
(l) summary of attendance and absences in
treatment services;
(m) any
grievance or complaint made by or against the client and actions taken by the
program;
(n) each crisis
intervention or critical incident report involving the client; and
(o) any signed agreement and consent
form.
(2) The licensee shall document a plan detailing how each program staff and client file is maintained and remains available to the office and other agencies legally authorized to access the files for seven years regardless of whether the program remains licensed.
Disclaimer: These regulations may not be the most recent version. Utah may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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