A medical record shall be maintained for each child

A medical record shall be maintained for each child. The medical record shall contain at least the following: 1. All details of the referral, admission, correspondence and papers concerning the child; 2. Entries in the medical record shall be in ink, shall be signed by the authorized personnel, to include name and title/discipline, and shall include at least the following: a. Physician’s orders; b. Flow charts of medications and treatments administered; c. Concise accurate information and initialed case notes reflecting progress toward protocol of care goals achievement or reasons for lack of progress; d. Documentation of nutritional management and special diets, as appropriate; e. Documentation of nursing, physical, occupational, speech, respiratory and social service assessments, goals, treatment plans, documentation of each treatment, to include date, time and therapy/treatments provided and progress of the child; f. An individualized protocol of care developed within ten (10) working days of admission and revised, as necessary, to include recommended changes in the therapeutic plan. The disposition to be followed in the event of emergency situations shall be specified in the plan of care; g. Medical history to include allergies and special precautions; h. Immunization record; i. Quarterly reviews of the protocol of care to update the plan in consultation with other professionals involved in the child’s care; j. A discharge order, written by the primary care or subspecialist physician, shall be documented and entered in the child’s record. A discharge summary, which includes the reason for discharge, shall also be included.