P.R. Laws tit. 24, § 6153l
All institutional providers shall keep and conserve a precise, clear, and legible record on each person who receives mental healthcare services. Such record shall contain all the requirements established under the laws and regulations approved by the Secretary of Health, in addition to the following information:
(a) The circumstances under which the person was evaluated or admitted, depending on the case.
(b) The documentation required for the patient’s placement.
(c) The clinical findings made by a qualified professional who renders mental health services.
(d) The diagnosis and diagnostic impression.
(e) The individualized treatment, recovery and rehabilitation plan.
(f) The prognosis and estimated release date.
(g) Any change that may arise in his/her state.
(h) Notations to record any situation relative to the person’s treatment and management, contemporaneous with the date on which the service was rendered.
(i) Psychotherapy notes shall be deemed not to be a part of the clinical record.
The clinical record shall be the property of the person who receives mental healthcare services, and as provided in § 6153g of this title, he/she may receive a copy of the complete clinical record pursuant to the conditions set forth in said § 6153g of this title. The clinical record shall be held under the custody of the institutional provider, and shall not be removed from the same, except otherwise provided by a court order, or by written request and payment of the corresponding fees by the person who receives mental healthcare services. The director of the institution shall oversee its confidentiality. To that effect, the institution shall provide all the necessary resources to establish mechanisms to protect the confidentiality, disclosure, and the clinical information contained in the record against unlawful use, unauthorized access, and alteration.
In the event that the patient needs his/her record because he/she is moving to another place outside of Puerto Rico, or decides to change to another health providing service, the institution shall furnish said record to the new service provider by means of the express authorization mechanism provided for under this chapter.
History —Oct. 2, 2000, No. 408, § 2.13, renumbered as § 2.13(B) and amended on Aug. 6, 2008, No. 183, § 12.