10A N.C. Admin. Code 70J.0204

Current through Register Vol. 39, No. 12, December 1, 2024

Section 70J .0204 - RECORDKEEPING

Client case record. An individual case record shall be maintained on each child that contains the following:

(1) written consent for placement;

(2) documentation of placement authority;

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

(4) consents for release of information, emergency medical treatment, family time/visitation;

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

(6) medical records and immunization records;

(7) intake study and related documents;

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

(9) family contact and visitation 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;

(10) birth certificate or other documentation that verifies the child's birth;

(11) court orders;

(12) documentation of medical insurance;

(13) consents for time-limited, audio-visual recording signed by both the child and parent or guardian , or legal custodian;

(14) progress notes; and

(15) 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.

10A N.C. Admin. Code 70J .0204

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;
Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. October 3, 2017.

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.