Section 801.780  Health Records

a)         The youth's health record shall, where appropriate, contain the following:

1)         The completed receiving screening form;

2)         Health appraisal data forms;

3)         All findings, diagnoses, treatments, and dispositions;

4)         Prescribed medications and their administration;

5)         Laboratory, x-ray, and diagnostic studies;

6)         Signature and title of documentor;

7)         Consent and refusal forms;

8)         Release of information forms;

9)         Place, date, and time of health encounters;

10)         Health service reports, such as, dental, mental health, and consultation reports;

11)         Treatment plan, including nursing care plan;

12)         Progress reports; and

13)         Discharge summary of hospitalization and other termination summaries.

b)         The method of recording entries in the records, the form and format of the records, and the procedures for their maintenance and safekeeping shall be approved by the health authority.

c)         The facility shall have a written policy and procedure which upholds the principle of confidentiality of the health record and supports the following requirements:

1)         The active health record shall be maintained separately from the youth's master record file.

2)         Access to the health record shall be controlled by the health authority. The Department's licensing or medical personnel shall have unrestricted access to a youth's medical record.

3)         The health authority shall share with the Chief Administrative Officer information regarding a youth's medical management, security, and ability to participate in programs.

d)         For a youth being temporarily transferred to other facilities, summaries or copies of the youth's medical history record shall be forwarded to the receiving facility prior to or upon arrival.  For permanent transfers, the active record shall accompany the youth.