§ 709.44. Client records.

 (a)  The project shall maintain a client record on an individual which shall include, but not be limited to:

   (1)  Histories, which include the following:

     (i)   Medical history.

     (ii)   Drug or alcohol history, or both.

     (iii)   Personal history.

   (2)  Consent forms.

   (3)  Psychosocial evaluation.

   (4)  Referral contact.

   (5)  Record of services provided.

 (b)  If applicable, the project shall also include the following items in the client record:

   (1)  Results of physical examination.

   (2)  Medication records.

   (3)  Treatment and rehabilitation plans.

   (4)  Follow-up information.

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

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