§ 5200.41. Records.

 (a)  Under section 602 of the Mental Health and Mental Retardation Act of 1966 (50 P. S. §  4602), and in accordance with recognized and acceptable principles of patient record keeping, the facility shall maintain a record for each person admitted to a psychiatric clinic. The record shall include the following:

   (1)  Patient identifying information

   (2)  Referral source.

   (3)  Presenting problems.

   (4)  Appropriately signed consent forms.

   (5)  Medical, social, and developmental history.

   (6)  Diagnosis and evaluation.

   (7)  Treatment plan.

   (8)  Treatment progress notes for each contact.

   (9)  Medication orders.

   (10)  Discharge summary.

   (11)  Referrals to other agencies, when indicated.

 (b)  Records shall also be maintained as follows:

   (1)  Legible and permanent.

   (2)  Reviewed periodically as to quality by the facility or clinical director as appropriate.

   (3)  Maintained in a uniform manner so that information can be provided in a prompt, efficient, accurate manner and so that data is accessible for administrative and professional purposes.

   (4)  Signed and dated by the staff member writing in the record.

 (c)  The records must comply with § §  5100.31—5100.39 (relating to confidentiality of mental health records).

 (d)  All case records shall be kept in locked and protected locations to which only authorized personnel shall be permitted access.