1. (1) There shall be an individual record for each person admitted to the facility.

2. (2) Each case record shall include:

   1. (i) identifying information about the person served and his family;
   2. (ii) source of referral, date of commencing service and name of staff member carrying overall responsibility for treatment and care;
   3. (iii) initial, intercurrent and final diagnoses including psychiatric, mental retardation or medical diagnoses in official terminology;
   4. (iv) reports of all diagnostic examinations and evaluations including findings and conclusions;
   5. (v) reports of all special studies performed including X-rays, clinical laboratory tests, clinical psychological testing, electro-encephalograms or psychometric tests;
   6. (vi) the individual written plan of care, treatment, and rehabilitation (section 85.6[b] of this Part);
   7. (vii) progress notes written and signed by all staff members having significant participation in the program of treatment and care;
   8. (viii) summaries of case conferences and special consultations;
   9. (ix) dated and signed prescriptions or orders for all medications with notation of termination dates;
   10. (x) a closing summary of the course of treatment and care; and
   11. (xi) documentation of any referrals to another agency.
3. (3) The certificate holder shall develop policies and procedures for recording information about persons not admitted for service such as persons on waiting lists, family members of persons served and persons whose applications for service are rejected by the facility.

4. (4) Patient records shall be safeguarded for confidentiality and be accessible only to authorized persons.

   (b) Statistical records and reports.

5. (1) Such statistical information shall be prepared and maintained as may be necessary for optimally effective operation of the facility and as may be required by the department.

   1. (i) Admissions and discharges, and other statistical information, shall be reported to the department as required and on the forms prescribed therefor.
   2. (ii) Statistical reporting shall be the responsibility of an appropriately qualified employee whose name and title shall be made known to the department.

   (2)

6. (3) Summaries of statistical information shall be reviewed at least annually by the governing body.

(a) Case records.