55 Pa. Code § 2390.124 - Content of records

Each client's record must include the following information:

(1) The name, sex, admission date, birthdate and place, Social Security number and dates of entry, transfer and discharge.

(2) The name, address and telephone number of parents, legal guardian and a designated person to be contacted in case of an emergency.

(3) The name and telephone number of a physician or source of health care.

(4) Written consent from the client, parent or guardian for emergency medical treatment.

(5) Physical examinations.

(6) Assessments as required under § 2390.151 (relating to assessment).

(7) A copy of the vocational evaluations, if applicable.

(8) Individual plan documents as required by this chapter.

(9) Incident reports related to the client.

(10) Copies of psychological evaluations, if applicable.

(11) Vocational evaluations as required under § 2390.159 (relating to vocational evaluation).

Notes

55 Pa. Code § 2390.124

The provisions of this § 2390.124 adopted May 9, 1986, effective 8/8/1986, 16 Pa.B. 1693; amended August 27, 2010, effective 8/28/2010, 40 Pa.B. 4935; amended October 4, 2019, effective in 120 days, 49 Pa.B. 5777.

The provisions of this § 2390.124 amended under sections 201(2), 403(b), 403.1(a) and (b), 911 and 1021 of the Human Services Code (62 P.S. §§ 201(2), 403(b), 403.1(a) and (b), 911 and 1021); and section 201(2) of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. § 4201(2)).