Section 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 8.26.6 NMAC 12 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.