N.M. Admin. Code § 8.26.6.20

Current through Register Vol. 35, No. 24, December 23, 2024

Section 8.26.6.20 - RECORDS

A. Child's record: The child's record shall contain at a minimum:

(1) intake information; any assessments relevant to the child's needs and well-being, and the discharge report with recommendations;

(2) education records: the community home shall maintain documentation of the child's educations status, needs, and history; the documentation shall include information provided by the school to the community home and is updated, at a minimum, each academic year;

(3) medical and behavioral health records: the community home shall maintain documentation of the child's medical and behavioral health needs, medications, and history including but not limited to:

(a) medical information;

(b) behavioral health history;

(c) developmental history;

(d) immunization record;

(e) history of serious illness or injury;

(f) physiological or psychological evaluations;

(g) past and current use of prescribed medications (including psychotropic medications);

(h) any complaints by the child indicating a current need for diagnosis and treatment;

(i) dates of any dental, visual, auditory, and physical examination and any treatment secured for any conditions discovered; and

(j) diagnosed behavioral health conditions and dates of any behavioral health treatment secured for those conditions.

(4) individualized case plan report: the child's record shall contain an individualized case plan report of services provided by the community home; for children in PSD custody, the report shall be provided to the PSD worker and shall include dates and locations of all professional staff visits with the child; and

(5) any incident reports.

B. Administrative records: Administrative records include but are not limited to:

(1) employee, student intern or volunteer records or files;

(2) policy and procedure; and

(3) a copy of the community home's license.

N.M. Admin. Code § 8.26.6.20

8.26.6.20 NMAC - N, 2/28/2014