7 –CLIENT RECORDS

A written record of each Recovery Works client assessed, and each client admitted to the program is maintained by the program.

REQUIRED ELEMENTS

Each client record shall include all information necessary to monitor the client’s condition and contain at least the following information:

  1. Name, Address, Telephone Number, Date of Birth, Sex, and Race;

  2. If applicable, the names addresses, and telephone numbers of parents, or guardians, or responsible parties;

  3. Person(s) to notify in the event of an emergency, if different than above;

  4. The client’s attending physician, if any;

  5. All records of screening and assessment, including a comprehensive psychosocial history;

  6. If applicable, documentation of why the client was not admitted for treatment and suggested referrals given to client;

  7. Written consent to receive treatment.

  8. Documentation of orientation.

  9. Rights of the client (State and Federal) including confidentiality and signed by the client;

  10. Individualized treatment plan and treatment notes (including drug administration records if applicable);

  11. Results of laboratory tests, as appropriate;

  12. Discharge summary and aftercare plan;

  13. Any other records relating to the client’s treatment and stay in the program such as written grievances, reports about discipline to include any use of emergency safety interventions if an incident resulting in injury occurs while the patient is at the program location, observations, etc.