For each person seen or admitted to program or service, a clinical record will be maintained as the legal record of services.  The record will contain sufficient information to identify the patient, justify the diagnosis(es) and treatment and provide accurate documentation of the therapy services that are rendered. At a minimum, each clinical record will include:  

Identification & Consent Data:

• Personal Identification Information

• Acknowledgement of Treatment Verification Process

• Authorization for Treatment 

• Acknowledgement of Financial Responsibiilty

• Notice of HIPAA Privacy Practices

History:

• Current Medical Information

• Pertinent medical history, past and present

• Date of onset for the current/referring condition(s)

• Diagnosis/Treatment Diagnosis

• Copies of medical/diagnostic records as appropriate

• Rehabilitation Referral/Orders

 Rehabilitation Services

• Plan of Care 

• Initial Therapy Evaluation

• Treatment Encounter Notes

• Progress Reports

• Discharge Summary which includes final diagnosis and prognosis