28 Pa. Code § 709.93 - Client records
(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.
Notes
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