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

2. (2) Each case record shall include:

   1. (i) legal admission documents;
   2. (ii) identifying information on the individual and his family;
   3. (iii) source of referral, date of commencing service and name of staff member carrying overall responsibility for treatment and care;
   4. (iv) initial, intercurrent and final diagnoses, including psychiatric, alcohol or substance abuse disorder or mental retardation or developmental disability diagnoses in official terminology;
   5. (v) reports of all diagnostic examinations and evaluations, including findings and conclusions;
   6. (vi) reports of all special studies performed, including X-rays, clinical laboratory tests, clinical psychological testing, electroencephalograms, psychometric tests;
   7. (vii) the individual written plan of care, treatment and rehabilitation prepared in accordance with section 580.6(a)(2) of this Part;
   8. (viii) progress notes that are written, signed, and dated by all staff members having significant participation in the program of treatment and care;
   9. (ix) summaries of case conferences and special consultations;
   10. (x) dated and signed prescriptions or orders for all medications with notation of termination dates;
   11. (xi) a closing summary of the course of treatment and care;
   12. (xii) autopsy findings if an autopsy is performed; and
   13. (xiii) documentation of any referrals to another agency.

3. (b) Patient records shall be safeguarded for confidentiality and accessible only to authorized persons, and shall be otherwise maintained in accordance with applicable State and Federal laws and regulations governing the privacy of individually identifying health information.

   1. (1) Such statistical information shall be prepared and maintained as may be necessary for optimally effective operation of the unit and as may be required by the office.
   2. (2) Admissions, discharges and other statistical information shall be reported to the office as required and in a form and format designated by the office.
   3. (3) Statistical reporting shall be the responsibility of an appropriately qualified employee whose name and title shall be made known to the office.
   4. (4) Summaries of statistical information shall be reviewed at least annually by the governing body.

   (c) Statistical records and reports.

(a) Case records.