9 CAR § 100-431. Health record maintenance and transmission — Health record

(a) A health record file on each youth shall be maintained at the facility or program where the youth is placed in a format approved by: (1) The Department of Health; or (2) Other health authority with oversight and in a manner that complies with state and federal privacy law. (b) The health record shall contain, at a minimum, the following information: (1) A health screen completed at the time the youth was received at the facility or program; (2) A copy of the youth’s medical treatment plan, if any, including: (A) Diagnoses; (B) Orders for physical therapy; (C) Occupational therapy; (D) Prescription and over-the-counter medication; (E) Nutrition plans; and (F) Other medical intervention; (3) All current pharmaceutical prescriptions and medication administration log; (4) A log of place, date, and time of all health encounters; (5) Health service reports, including: (A) Medical; (B) Dental; (C) Optometric; and (D) Psychiatric; (6) All health appraisal data forms; (7) All consent and refusal forms; and (8) The signature and title of the documenter.