Pa. Code 5210.26

Records

This section establishes recordkeeping requirements for partial hospitalization programs in Pennsylvania, specifying the required contents of each patient record (e.g., identifying information, diagnosis, treatment plan, progress notes, discharge summary) and standards for how records must be maintained (legible, signed, dated, locked, and confidential). Facility directors must periodically review records for quality, and all records must comply with Pennsylvania's mental health confidentiality regulations at §§ 5100.31–5100.39. These requirements apply to every person admitted to the partial hospitalization program.

55 Pa. Code § 5210.26 - Records 

 State Regulations 

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(a)
 Under section
 602 of the Mental Health and Mental Retardation Act of 1966 (
50 P. S. §
 
4602
) and in accordance with recognized and
 acceptable principles of patient recordkeeping, the record shall include the
 following:
(1)
 Patient identifying
 information.

(2)
 Referral
 source.

(3)
 Presenting
 problem.

(4)
 Consent
 forms.

(5)
 Medical, social and
 developmental history.

(6)

 Diagnosis and evaluation.

(7)

 Treatment plan.

(8)
 Treatment
 progress notes for each contact.

(9)
 Medication orders.

(10)
 Discharge summary.

(11)
 Referrals to other agencies, when
 indicated.

(b)
 Records
 shall also be maintained as follows:
(1)

 Legible and permanent.

(2)
 Reviewed
 periodically as to quality by the facility director.

(3)
 Maintained in a uniform manner so that
 information can be provided in a prompt, efficient, accurate manner and so that
 data is accessible for administrative and professional purposes.

(4)
 Signed and dated by the staff member
 writing in the record.

(c)

 The facility shall maintain a record on each person admitted to the partial
 hospitalization program.

(d)
 The
 records shall comply with §§
 
5100.31
-
5100.39
 (relating to
 confidentiality of mental health records).

(e)
 Case records shall be kept in locked,
 protected locations to which only authorized personnel shall be permitted
 access.

Notes

55

 Pa. Code §
 
5210.26

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