The therapeutic community’s policies and procedures shall:

1. (1) Define the content of the client’s medical record;
2. (2) Define storage, retention, and destruction requirements for client medical records;
3. (3) Require client medical records be confidentially maintained in locked equipment under secure measures;

4. (4) Require legible entries in client medical records:

   1. (A) Signed with first name or initial, last name, and credentials; and
   2. (B) Dated by the person making the entry;
5. (5) Require the client's name be typed or written on each sheet of paper or page in the client record;
6. (6) Require a signed consent for treatment before the client is admitted; and
7. (7) Require a signed consent for follow-up before any contact after discharge is made.