Rule 5122-27-02 | Individual client record obligation.
(A) Except as provided in rule 5122-27-02.1 of the Administrative Code, a provider is to create and maintain an individual client record for each client that contains, at a minimum, all of the following:
(1) Findings from the assessment of the client done by the provider or the provider's contractor, the provider's or contractor's diagnosis of the client, treatment details, progress notes, and any other information the provider or contractor has regarding the client's physical and behavioral health. Consistent with rule 5122-29-03 of the Administrative Code, the assessment may have been completed by another provider if that assessment had been completed within the preceding twelve months.
(2) Documentation that the risks and benefits of treatment were explained to the client and documentation of any consent, refusal to consent, or withdrawal of consent that the client gave to the provider. To the extent applicable, consent by minors is to be done in accordance with section 3719.012 or 5122.04 of the Revised Code.
(3) Documentation regarding the service fees the provider charges and whether the client or the client's parent or guardian is responsible for payment of any portion not covered by insurance or another funding source.
(4) Documentation that the provider gave the client or the client's parent all of the following:
(a) The provider and client expectations, for example, mandatory attendance, maintaining a sober living environment, and the consequences of not fulfilling the expectations.
(b) In accordance with 42 C.F.R. 2.22, notice that federal laws and regulations protect the confidentiality of certain client records and a summary of those federal laws and regulations.
(5) A copy of each authorization for release of information signed by the client.
(6) If the client attended educational sessions pertaining to substance use disorders, documentation verifying attendance at such sessions.
(7) If the client receives certifiable services or supports via telehealth, the provider is to communicate the potential risks to the client with a minimum of the following:
(a) Clinical aspects of receiving telehealth services;
(b) Security considerations when receiving telehealth services; and
(c) Confidentiality considerations when receiving telehealth services.
(B) In addition to meeting the recordkeeping mandates in paragraph (A) of this rule, a provider that provides general services as defined in rule 5122-29-03 of the Administrative Code is to maintain, as part of the individual client record, documentation regarding the medical activities of the services, including documentation regarding prescriptions issued and reviews of test results.
(C) Except as provided in rule 5122-27-02.1 of the Administrative Code, a provider is to maintain records concerning certifiable services or supports for one of the following time periods, as applicable:
(1) If the client initiated certifiable services or supports with the provider on or after the client's eighteenth birthday, seven years after a client was discharged from a program or certifiable services or supports are no longer provided;
(2) If the client initiated certifiable services or supports with the provider before the client's eighteenth birthday and the client was not diagnosed with a developmental disability or severe emotional disturbance before the client's eighteenth birthday, the later of (a) seven years after the client was discharged from a program or certifiable services or supports are no longer provided or (b) until the client's twenty-fifth birthday; or
(3) If the client initiated certifiable services or supports with the provider before the client's eighteenth birthday and the client was diagnosed with a developmental disability or severe emotional disturbance, the later of (a) seven years after the client was discharged from a program or certifiable services or supports are no longer provided or (b) until the client's twenty-eighth birthday.
Last updated August 3, 2026 at 8:37 AM
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