10A NCAC 70I .0506. CLIENT RECORDS

(a)  A residential child-care facility shall maintain a client record for each child which contains the following:

(1)           documentation of placement authority by parents, guardian or legal custodian;

(2)           written placement consent and agreement;

(3)           intake study and related documents;

(4)           completed application for services that includes demographic information on the child and the child's family;

(5)           documentation that verifies the child's birth;

(6)           pre-admission medical examination report or a medical examination report completed within two weeks of admission (unless the child's health status indicates the completion of a medical examination report sooner) and copies of subsequent medical examination reports;

(7)           immunization records;

(8)           out-of-home family services agreement and reviews;

(9)           court orders;

(10)         visitation and contact plan, including type, duration, location both on-site and off-site, and frequency, as well as any rationale for restrictions on family involvement; the facility shall maintain documentation of all family time;

(11)         consents for release of information;

(12)         consent for emergency medical treatment;

(13)         consents for out-of-state field trips;

(14)         consents for time-limited audio-visual recording signed by both the child and parents or guardian,  and legal custodian (if applicable);

(15)         ongoing record of medical and dental care;

(16)         documentation of medical insurance;

(17)         progress notes; and

(18)         discharge summary including date of discharge, time of discharge and the name,  address,  telephone number and relationship of the person or agency to whom the child was discharged, a summary of services provided during care, needs which remain to be met and plans for the services needed to meet these goals.

(b)  The residential child-care facility shall maintain client records for the purpose of:

(1)           protecting the legal rights of the child, parents, guardian or legal custodian, and the facility;

(2)           documenting service provision to the child and family, including an evaluation of effectiveness of services provided; and

(3)           providing a source of information about individual children, as well as information for the facility in planning its program of care and services.

(c)  Staff members recording entries in client records shall date, initial or sign entries.

 

History Note:        Authority G.S. 131D-10.5; 143B-153;

Eff. July 1, 1999 (See S.L. 1999, c. 237, s. 11.30);

Amended Eff. October 1, 2008; July 18, 2002.