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.