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Utah Admin. Code R432-700-17 — Client Records

UtahregulationUtah Department of Health and Human Services· effective 2023-07-06

What this rule requires your agency to do

  • 1Each client record must contain identification data, responsible-party and primary-care-provider contacts, a written plan of care, a signed/dated assessment, referral reasons, and a suitability-of-residence statement (R432-700-17(5)(a)-(h)).(Utah Admin. Code R432-700-17 — Client Records)
  • 2For clients receiving skilled services, the record must additionally include diagnosis, medical/surgical history, medications/treatments, allergies, continuity-of-care summaries, and clinical notes describing condition and significant changes (R432-700-17(6)(a)-(f)).(Utah Admin. Code R432-700-17 — Client Records)
  • 3The licensee must develop and implement record-keeping policies addressing use of records by authorized staff, content, confidentiality, retention, and storage, and maintain records in an organized format (R432-700-17(1)-(2)).(Utah Admin. Code R432-700-17 — Client Records)
  • 4The agency must maintain a client record identification system to facilitate locating each client's current or closed record (R432-700-17(3)).(Utah Admin. Code R432-700-17 — Client Records)
  • 5The licensee must ensure record entries are dated and authenticated with the signature or identifiable initials of the person making the entry, and document each service and its outcomes (R432-700-17(4)(b)-(c)).(Utah Admin. Code R432-700-17 — Client Records)
  • 6The licensee must maintain an accurate, up-to-date record for each client receiving service (R432-700-17(4)).(Utah Admin. Code R432-700-17 — Client Records)
  • 7Each person who has client contact or provides a service in the client's residence must enter a clinical note of that contact/service in the client's record (R432-700-17(4)(a)).(Utah Admin. Code R432-700-17 — Client Records)
  • 8Each client record must contain signed and dated clinical notes for each contact/home visit and a written termination-of-services summary describing care provided, course, reason for discharge, client status, and any referral/transfer (R432-700-17(5)(j)-(k)).(Utah Admin. Code R432-700-17 — Client Records)

Applies to: personal care

Requires the licensee to maintain organized, confidential, up-to-date client records with a client-identification system, clinical notes for each contact, dated and authenticated entries, and enumerated required content (identification, plan of care, assessment, clinical notes, termination-of-services summary) plus additional items for clients receiving skilled services. Framework topic: Clinical Records & Documentation.

Regulatory information, not legal advice — always confirm against the cited official source. Verification reduces error; it does not certify compliance.