Section 117.125  Individuals' records and informed consent

a)         The individual or guardian shall give informed consent for the release of information and to participate in the services specified in the service/treatment plan, which shall be documented in the individual's case record.

b)         The Department shall maintain a roster of all applicants who have been chosen and have been determined eligible for the programs described in this Part.

c)         The Department shall maintain a permanent case record for each individual who has been chosen and determined eligible.  Control and protection of the record shall be governed by the Act.

d)         Department staff shall maintain a continuous, chronological record of all activities and events in the case records.  Events and activities shall be documented in a standard format with sufficient specificity that progress can be monitored by an uninformed reviewer without additional information from responsible staff.

e)         Department-designated agencies shall also maintain a case record for each individual served.  Control and protection of the records shall be governed by the Act.