10A NCAC 28F .0605        RECORD KEEPING

(a)  A client record shall be maintained for each individual and shall include but not be limited to:

(1)           application for admission;

(2)           signed informed consent form covering participation in the project;

(3)           physical examination and review of systems;

(4)           description of procedures performed;

(5)           special tests;

(6)           adverse reactions and incidents; and

(7)           termination summary.

(b)  A complete description of medications administered shall be placed in the client record when it no longer would interfere with the purpose of the research to do so.

 

History Note:        Authority G.S. 122C‑112(b)(3); 122C‑210.2;

Eff. January 1, 1989.