This regulation requires substance use disorder treatment projects in Pennsylvania to maintain complete client records containing specified elements, including consent forms, medication records, treatment plans, progress notes, discharge summaries, and follow-up information. Records must be kept on standardized project forms. As a client records section within a chapter governing SUD facility licensing (which includes detoxification and treatment/rehabilitation), this requirement applies to all facilities licensed under Chapter 709.
View official source28 Pa. Code § 709.93 - Client records State Regulations Compare (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 28 Pa. Code § 709.93 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