§ 4210.122. Patient records and reports.
(a) For administrative and epidemiological purposes, the base service unit shall maintain a central file for each patient in its area. This record will include as a minimum:
(1) A history of all movement of the patient through services provided directly by the base service unit as well as all other services provided to him through the county program.
(2) Brief progress notes prepared as services are provided reporting the status of the patients treatment either by the base service unit or by other providers of service.
(b) All of this required information is contained in the following five reports:
(1) Monthly Contract Report.
(2) Service Rendered Report.
(3) Authorization for Service.
(4) Intake and Proposed Service Plan.
(5) Prescription and Pharmacist Invoice.
(c) Details on the preparation and distribution of these forms are contained in a separate manual, Patient Service Accountability System.
(d) In addition the base service unit shall maintain a confidential clinical case record file for each patient under treatment by its own staff.
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