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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 51 Pa.B. 6384 (October 2, 2021).

28 Pa. Code § 709.63. Client records.

§ 709.63. Client records.

 (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.

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