(a) Las circunstancias bajo las cuales la persona fue evaluada o ingresada, según el caso.
(b) La documentación requerida para su ingreso.
(c) Los hallazgos clínicos de un profesional calificado que provea servicios de salud mental.
(d) El diagnóstico o impresión diagnóstica.
(e) El plan individualizado de tratamiento, recuperación y rehabilitación.
(f) Pronóstico y fecha estimada de alta.
(g) Cualquier cambio que surja en su estado.
(h) Anotaciones que evidencien cualquier situación relativa al tratamiento y manejo de la persona, contemporánea a la fecha en que se prestó el servicio.
(i) No se considerará parte del expediente clínico, las notas psicoterapéuticas.
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