20 CAR § 416-310 – Other records content

(a) The client record shall contain copies of all consultation reports concerning the client.
(b) When psychometric or psychological testing is done, the client record shall contain:
1. (1) A copy of a written report describing the test results; and
2. (2) Implications and recommendations for treatment.
(c) The client medical record shall contain any additional information relating to the client that has been secured from sources outside the therapeutic community.