465 IAC 2-9-46 Child's records

Sec. 46. (a) The child caring institution shall maintain a record of the following information for each child admitted: (1) Name. (2) Sex. (3) Date of birth. (4) Name, address, and marital status of both parents. (5) Name, age, and address of child's brothers and sisters, step or half-brothers and sisters, and near relatives. (6) Religious information necessary to provide appropriate services. (7) Information upon which the admission decision was based. (8) Name of agencies which have had contact with the child and the family and dates of contacts. (9) Name and address of person or placing agency requesting admission. (10) Date of admission. (11) Written agreement with the placing agency or person. (12) A copy of the court order or other document authorizing placement of the child in the child caring institution. (13) SDPW case plan, if applicable. (14) Initial assessment of child and family and resulting treatment plan. (15) Written quarterly progress reports and six (6) month treatment plan revisions. (16) Documentation of efforts to provide services to the child's family. (17) Documentation of any discipline of a child which results in an injury. (18) School report, including teachers' evaluation of child's progress. (19) Report by any specialist, such as psychiatrist or psychologist, if applicable. (20) Discharge information required under section 67 of this rule. (b) The child caring institution shall keep case records confidential and shall safeguard against the possibility of loss by fire, theft, or destruction. (c) Staff entries in case records shall be dated and signed. (d) The child caring institution shall keep each child's case record for at least five (5) years after the child is discharged. For records older than five (5) years, the child caring institution shall retain at least the information required in subsection (a)(1) through (a)(5), (a)(10), (a)(12), and (a)(20).