This regulation requires substance use disorder treatment projects to maintain complete client records containing specified elements, including consent forms, treatment and rehabilitation plans, medication records, progress notes, discharge summaries, and follow-up information. Records must be kept on standardized project forms. As a client records requirement within Chapter 709, which governs licensing of drug and alcohol treatment facilities including detoxification and treatment/rehabilitation services, this section applies to all facilities licensed under that chapter.
View official source28 Pa. Code § 709.83 - 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) Treatment and rehabilitation plan. (3) Client-related correspondence. (4) Case consultation notes. (5) Medication records. (6) Aftercare plans, if applicable. (7) Referral contact. (8) Record of services provided. (9) Progress notes. (10) Discharge summary. (11) Follow-up information. (12) Verification that work done by the client at the project is an integral part of the treatment and rehabilitation plan. (b) The project shall develop and maintain client records on standardized project client record forms. Notes 28 Pa. Code § 709.83 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