Pennsylvania Code & Bulletin
COMMONWEALTH OF PENNSYLVANIA

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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 54 Pa.B. 488 (January 27, 2024).

28 Pa. Code § 709.93. Client records.

§ 709.93. 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)  Medication records.

   (3)  Record of services provided.

   (4)  Referral contact.

   (5)  Progress notes.

   (6)  Individual treatment and rehabilitation plan.

   (7)  Client-related correspondence.

   (8)  Case consultation notes.

   (9)  Aftercare plan, if applicable.

   (10)  Discharge summary.

   (11)  Follow-up information.

 (b)  The project shall develop and maintain client records on standardized project client record forms.



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