§ 711.43. Client records.
(a) Record requirements. The project shall maintain a client record on an individual. In addition to the requirements contained in § 115.32 (relating to contents), the client record shall include the following:
(1) Histories, which include the following:
(i) Medical history.
(ii) Drug or alcohol history.
(iii) Personal history.
(2) Drug and alcohol consent forms.
(3) Psychosocial evaluation.
(4) Referral contact.
(5) Record of services provided.
(b) Additional information. If applicable, the project shall include the following items in the client record:
(1) Drug and alcohol treatment and rehabilitation plans.
(2) Follow-up information.
(c) Client access to records. A client has the right to inspect his own records. The project director may temporarily remove portions of the record prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented and kept on file.
(1) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies; disclosure of client-oriented information). The procedure shall include, but not be limited to:
(i) Confidentiality of client identity and records.
(ii) Staff access to client records.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(i) The name of the person, agency, organization to whom disclosure is made.
(ii) The specific information disclosed.
(iii) The purpose of disclosure.
(iv) The dated signature of client or guardian.
(v) The dated signature of witness.
(vi) The expiration date of the consent.
(3) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
(4) Where consent is not required, the project personnel shall:
(i) Fully document the disclosure in the client records.
(ii) Inform the client, as readily as possible, that the information was disclosed, for what purposes, and to whom.
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