1. (a) A client record shall be maintained for each individual and shall include but not be limited to:

   1. (1) application for admission;
   2. (2) signed informed consent form covering participation in the project;
   3. (3) physical examination and review of systems;
   4. (4) description of procedures performed;
   5. (5) special tests;
   6. (6) adverse reactions and incidents; and
   7. (7) termination summary.
2. (b) A complete description of medications administered shall be placed in the client record when it no longer would interfere with the purpose of the research to do so.

History Note: Authority G.S. 122C‑112(b)(3); 122C‑210.2;
Eff. January 1, 1989;
Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. August 24, 2019.