Pa. Code 5200.41

Records

This section requires psychiatric outpatient clinics in Pennsylvania to maintain a complete individual record for each client receiving services, including identifying information, assessments, treatment plans, progress notes, medication orders, discharge summaries, and referrals. Records must be legible, permanent, reviewed twice yearly for quality, maintained uniformly for administrative and professional access, and signed and dated by the authoring staff member. All protected records, whether written or electronic, must be secured in compliance with applicable federal and state privacy and confidentiality laws.

55 Pa. Code § 5200.41 - Records 

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(a)
 Under section
 602 of the Mental Health and Intellectual Disability Act of 1966 (
50 P.S. §
 
4602
), and in accordance with recognized and
 acceptable principles of recordkeeping, the facility shall maintain a record
 for each individual receiving services from a psychiatric outpatient clinic.
 The record must include the following: 
(1)

 Identifying information.

(2)

 Referral source.

(3)
 Assessment
 including presenting problems.

(4)

 Appropriately signed consent forms.

(5)
 Medical, social and developmental
 history.

(6)
 Diagnosis and
 evaluation.

(7)
 Treatment plan and
 updates.

(8)
 Treatment progress
 notes for each contact.

(9)

 Medication orders.

(10)
 Discharge
 summary.

(11)
 Referrals to other
 agencies, when indicated.

(12)
 A
 written recommendation from a LPHA acting within the practitioner's scope of
 practice for any MMHT services provided.

(b)
 Records shall also be maintained as
 follows:
(1)
 Legible and permanent.

(2)
 Reviewed twice a year as to quality by
 the director, clinical supervisor or psychiatrist.

(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)

 All protected individual records, written and electronic, shall be secured in
 accordance with all applicable Federal and State privacy and confidentiality
 statutes and regulations.

Notes

55

 Pa. Code §
 
5200.41

The
 provisions of this § 5200.41 amended October 11, 2019, effective
 
10/12/2019
, 49 Pa.B.
 5943.

The provisions of this § 5200.41 amended under section
 1021 of the Human Services Code (
62 P.S. §
 
1021
);
 sections 105 and 112 of the Mental Health Procedures Act (
50 P.S. §§
 
7105
 and
 
7112
); and section 201(2) of
 the Mental Health and Intellectual Disability Act of 1966 (
50 P.S. §
 
4201(2)
).

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