Pa. Code 711.83

Client records

This section establishes client record requirements for drug and alcohol treatment projects operating under Chapter 711, including mandatory record contents (consent forms, treatment plans, progress notes, aftercare plans, and follow-up information), client rights to inspect their own records, and detailed confidentiality and informed-consent procedures for disclosure of client information. Facility operators must develop written confidentiality procedures, obtain written informed consent before disclosing client information, and fully document any disclosures made without consent. These requirements apply to the substance use outpatient/project settings licensed under this chapter.

28 Pa. Code § 711.83 - Client records 

 State Regulations 

 Compare

(a)

Record requirements.
 There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in §
 
115.32
 (relating to contents), the client record shall include the following: 
(1)
 Drug and alcohol consent forms.

(2)
 Referral contact.

(3)
 Individualized drug and alcohol treatment and rehabilitation plan.

(4)
 Progress notes.

(5)
 Aftercare plans, if applicable.

(6)
 Record of services provided.

(7)
 Follow-up information.

(8)
 Verification that work done by the client at the project is an integral part of this treatment and rehabilitation plan.

(b)

Client access to records.
 A client has the right to inspect his own records. The Project Director may temporarily remove portions of the record, prior to the inspection by the client, if that director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented and kept on file.

(c)

Confidentiality.

(1)
 A written procedure shall be developed by the project director which complies with 4 Pa.Code §
255.5
 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(i)
 Confidentiality of client identity and records.

(ii)
 Staff access to client records.

(2)
 The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to: 
(i)
 The name of the person, agency or organization to whom disclosure is made.

(ii)
 The specific information disclosed.

(iii)
 The purpose of disclosure.

(iv)
 The dated signature of the client or guardian.

(v)
 The dated signature of a witness.

(vi)
 The expiration date of the consent.

(3)
 A copy of a client consent shall be offered to the client and a copy maintained in the client records.

(4)
 Where consent is not required, the project personnel shall: 
(i)
 Fully document the disclosure in the client records.

(ii)
 Inform the client, as readily as possible, that the information was disclosed, for what purposes, and to whom.

Notes

28
 Pa. Code §
 
711.83

State regulations are updated quarterly; we currently have two versions available.
 Below is a 
comparison between our most recent version and the prior quarterly release.

 More comparison features will be added as we have more versions to compare.

 No prior version found.

 State Regulations Toolbox