Each client’s record shall include:

1. (1) Personal information including:

   1. (i) The name, sex, admission date, birth date and social security number of the client.
   2. (ii) The race, height, weight, color of hair, color of eyes and identifying characteristics.
   3. (iii) The language or means of communication spoken or understood by the client and the primary language used in the client’s natural home, if other than English.
   4. (iv) Documentation of a person’s designation or appointment as a responsible party, as described in § 11.8 (relating to responsible party).
   5. (v) A photograph taken within the last 5 years.
2. (2) Unusual incident reports related to the client.
3. (3) Medical reports and progress notes, if any.
4. (4) Intake screening forms.
5. (5) Individual care plans.
6. (6) Signed release of information form.
7. (7) Signed enrollment agreement.

Cross References

This section cited in 6 Pa. Code § 11.13 (relating to administration and organization); 6 Pa. Code § 11.194 (relating to record location); and 6 Pa. Code § 11.212 (relating to applicability).