ARM 37.106.3221. CASE RECORDS

(1) A facility must maintain a written case record for each resident which contains administrative, treatment, and educational data from the time of admission until the time the resident is discharged from the facility. (2) The case record must include: (a) the name, sex, and birth date of the resident; (b) the name, address, and telephone number of the parent or legal guardian of the resident; (c) date of admission; (d) current immunization records and documentation of exemptions per facility policy; (e) date of discharge, person, and signature whom the resident was released to, and signed discharge summary; (f) all documents related to the referral of the resident to the facility; (g) current custody and parent or legal guardianship documents or other documents verifying legal custody of the parent or legal guardian placing the resident per facility policy; (h) the resident’s court status, if applicable; (i) a copy of the resident’s birth certificate; (j) consent forms signed by the parent or legal guardian prior to placement allowing the facility to authorize all necessary medical care, routine tests, immunization, and emergency medical or surgical treatment; (k) cumulative health records including medical history provided by the parent or legal guardian; (l) education records and reports, including but not limited to report cards and individual education plan reports; (m) treatment or clinical records and reports; (n) records of physical restraints and special or serious incidents; (o) case plans, treatment plans, all updates and related material; (p) social assessment that is current to date of placement; and (q) an immediate needs assessment and assigned responsibilities. (3) Resident records must be maintained at the facility for a minimum of six years.