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Title: Section 425.21 - Clinical records

Effective Date


425.21 Clinical records. The operator must:

(a) provide a clinical record for each registrant in accordance with the clinical records requirements of section 415.22 of this Subchapter;

(b) ensure that all reports and information pertaining to registrant care and planning are entered promptly;

(c) ensure that all entries are dated and authenticated by the person making the entry or ordering the services;

(d) ensure that all clinical records for registrants referred by a managed care plan are made available to the referring managed care plan;

(e) ensure that the record is kept in a place convenient for use by authorized staff; and

(f) retain intact clinical records and all other records of registrants and keep them readily accessible in a safe and secure place. Such records shall be retained safely and securely for a period of six years following discharge or cessation of operation of services. In the case of a minor, retention shall be for three years after reaching majority (18 years of age).


VOLUME C (Title 10)