55 Pa. Code § 5230.21. Content of individual record.

INDIVIDUAL RECORD

§ 5230.21. Content of individual record.

A PRS agency shall develop and maintain a record for an individual served containing the following:
   (1)  Information that identifies the individual.
   (2)  Eligibility for PRS, including diagnosis.
   (3)  Referral source, reason for referral and recommendation by an LPHA.
   (4)  A signed set of documents providing the following:
     (i)   Individual consent to receive services.
     (ii)   Individual consent to release information to other providers.
     (iii)   Verification that the individual received and had an opportunity to discuss the oral and written versions of the PRS statement of rights under §  5230.41 (relating to PRS statement of rights).
   (5)  An assessment and updates.
   (6)  The IRP.
   (7)  Staff documentation of IRP outcomes.
   (8)  Staff documentation of coordination with other services and supports.
   (9)  Discharge summary.

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