This regulation requires licensed substance use disorder treatment projects in Pennsylvania to maintain comprehensive client records, including medical, drug/alcohol, and personal histories, consent forms, psychosocial evaluations, referral contacts, and records of services provided. Where applicable, records must also include physical examination results, medication records, treatment and rehabilitation plans, and follow-up information. All client records must be maintained on standardized project forms. This section is part of a chapter governing SUD facility licensing under DDAP.
View official source28 Pa. Code § 709.44 - Client records State Regulations Compare (a) The project shall maintain a client record on an individual which shall include, but not be limited to: (1) Histories, which include the following: (i) Medical history. (ii) Drug or alcohol history, or both. (iii) Personal history. (2) Consent forms. (3) Psychosocial evaluation. (4) Referral contact. (5) Record of services provided. (b) If applicable, the project shall also include the following items in the client record: (1) Results of physical examination. (2) Medication records. (3) Treatment and rehabilitation plans. (4) Follow-up information. (c) The project shall develop and maintain client records on standardized project client record forms. Notes 28 Pa. Code § 709.44 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