This regulation requires licensed drug and alcohol treatment projects to maintain complete client records containing specified elements, including consent forms, drug and alcohol support plans, progress notes, medication records, service documentation, aftercare plans, discharge summaries, follow-up information, documentation of client work as part of the support plan, and special dietetic needs. Records must be kept on standardized project forms. As a client records section within Chapter 709, which governs licensing of drug and alcohol treatment facilities including detoxification and treatment/rehabilitation services, this requirement applies to those licensed SUD facility types.
View official source28 Pa. Code § 709.63 - 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) Drug and alcohol support plan. (3) Progress notes. (4) Medication records. (5) Record of services provided. (6) Aftercare plans, if applicable. (7) Discharge summary. (8) Follow-up information. (9) Verification that work done by the client at the project is an integral part of the client's drug and alcohol support plan. (10) Documentation of special dietetic needs, if applicable. (b) The project shall develop and maintain client records on standardized project client record forms. Notes 28 Pa. Code § 709.63 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