Section 17a-20-54 - Case records(a) Each clinic shall maintain a current confidential case record for each child in treatment including family, social and health history. The case record shall contain but not be limited to pre-admission data; the reason for admission; results of all diagnostic assessments performed; a summary of admission information; the individual treatment plan; a record of all care and services, including medical services, provided by the clinic; progress notes on the child in treatment; reviews of the treatment plan; the plan for discharge and disposition; a discharge summary and all other documents received and required for the treatment of a particular child.(b) The case record shall contain only information pertaining to a particular child.(c) The case record shall include contact summaries where appropriate and copies of special behavior contracts used for a particular child.Conn. Agencies Regs. § 17a-20-54
Adopted effective February 1, 1999