(a)

1. (1) An ADDT must maintain a separate, updated, and complete service record for each client documenting the services provided to the client and all other documentation required under this part.
2. (2) Each client service record must be uniformly organized and readily available for review by the Division of Provider Services and Quality Assurance at the ADDT’s location.

3. (3) A client’s service record must include a summary document at the front that includes:

   1. (A) The client’s:

(i) Full name;

1. (ii) Address and county of residence;

   1. (iii) Telephone number and, if available, email address;

      1. (iv) Date of birth;
      2. (v) Primary language;
      3. (vi) Diagnoses;
      4. (vii) Medications, dosage, and frequency, if applicable;
      5. (viii) Known allergies;
      6. (ix) Entry date into the ADDT;
      7. (x) Exit date from the ADDT;
      8. (xi) Medicaid number; and
      9. (xii) Commercial or private health insurance information or managed care organization information, if applicable;
   2. (B) Name, address, phone number, email address, and relationship of the client’s custodian or legal guardian; and
   3. (C) Name, address, and phone number of the client’s primary care physician.

(b) A client’s service record must include at least the following information and documentation:

1. (1) The client’s:

   1. (A) ITP;
   2. (B) Behavioral management plan;
   3. (C) Daily activity logs; and
   4. (D) Medication management plan and medication logs;
2. (2) Copies of any assessments or evaluations completed on the client; and

3. (3) Copies of any orders that place the client in the custody of another person or entity.

   1. (c) An ADDT must ensure that each client service record is kept confidential and available only to:
4. (1) Employees who need to know the information contained in the client’s service record;
5. (2) Persons or entities who need to know the information contained in the client service record in order to provide services to the client;
6. (3) The division and any governmental entity with jurisdiction or other authority to access the client’s service record;
7. (4) The client’s legal guardian or custodian; and

8. (5) Any other individual authorized in writing by the legal guardian or custodian.

   1. (d) An ADDT must keep client service records in a file cabinet or room that is always locked.

(e)

1. (1) An ADDT may use electronic records in addition to or in place of physical records to comply with this section.
2. (2) An ADDT provider that uses electronic records must take reasonable steps to backup all electronic records and reconstruct a client’s service record in the event of a breakdown in the ADDT’s electronic records system.