WAC 110-145-3490. Medical records for medically fragile children and youth

Licensees providing care for medically fragile children and youth must meet the following documentation requirements in addition to the requirements in WAC 110-145-2900 : (1) Obtain documentation when children or youth have been in care for more than 30 calendar days of: (a) A physical examination and diagnosis by a licensed health care provider; (b) Information about the child's or youth's daily care, if applicable including, but not limited to: (i) Treatment plans; (ii) Medications; (iii) Observations; (iv) Medical examinations; (v) Physicians' orders; (vi) Proper treatment for allergic reactions; (vii) Consent authorizations; (viii) Releases; (ix) Diagnostic reports; and (x) Revised assessments; (c) Upon discharge, a summary including: (i) Diagnoses, treatments, and prognosis by the individual responsible for providing care; and (ii) Any instructions and referrals for continuity of care; and (d) Evidence of meeting criteria for eligibility for services from DDCS, if applicable. (2) If a medication order is given over the phone from a licensed health care provider, licensees must: (a) Have an RN or LPN receive the order; and (b) Obtain a signed copy of the order from a licensed health care provider within 72 hours of the order.