Rule 111-8-71-.10 - RecordkeepingAn individual care record shall be maintained for each client admitted to the facility. Case records must be maintained in a central location, and contain the following materials:
(a) Case identification information;(b) Names, addresses, and telephone numbers of responsible family members, guardians, or representatives;(c) Names, addresses, and telephone numbers of emergency contacts to include the client's physicians;(d) Admissions documentation;(e) The client's complete written assessment;(f) The client's written program plan, including the designation of a case manager; and(g) Signed and dated progress reports, notes or similar documentation related to the mental and physical health, treatment, and rehabilitation of the client to include current drug regimens, treatment, and dietary needs.Ga. Comp. R. & Regs. R. 111-8-71-.10
O.C.G.A. § 31-7-2.1.
Original Rule entitled "Recordkeeping" adopted. F. Sep. 9, 2013; eff. Sept. 29, 2013.