This regulation requires substance use disorder treatment projects licensed under Chapter 709 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 record-keeping section within a chapter governing SUD facility licensure (which explicitly includes detoxification and treatment/rehabilitation), this rule applies to those licensed SUD settings.
View official source28 Pa. Code § 709.53 - 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) Individualized treatment and rehabilitation plan. (7) Client-related correspondence. (8) Case consultation notes. (9) Aftercare plan, if applicable. (10) Discharge summary. (11) Follow-up information. (12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan. (13) 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 § 709.53 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