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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 54 Pa.B. 1806 (March 30, 2024).

55 Pa. Code § 5200.41. Records.


§ 5200.41. Records.

 (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.


   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)).


   The provisions of this §  5200.41 amended October 11, 2019, effective October 12, 2019, 49 Pa.B. 5943. Immediately preceding text appears at serial pages (368119) to (368120).

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