Current through Register Vol. 54, No. 25, June 22, 2024
Section 5210.26 - Records(a) Under section 602 of the Mental Health and Mental Retardation Act of 1966 (50 P. S. § 4602) and in accordance with recognized and acceptable principles of patient recordkeeping, the record shall include the following:(1) Patient identifying information.(5) Medical, social and developmental history.(6) Diagnosis and evaluation.(8) Treatment progress notes for each contact.(11) Referrals to other agencies, when indicated.(b) Records shall also be maintained as follows:(1) Legible and permanent.(2) Reviewed periodically as to quality by the facility director.(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) The facility shall maintain a record on each person admitted to the partial hospitalization program.(d) The records shall comply with §§ 5100.31-5100.39 (relating to confidentiality of mental health records).(e) Case records shall be kept in locked, protected locations to which only authorized personnel shall be permitted access.