Section 210 IAC 8-8-40 - Juvenile health recordsAuthority: IC 11-8-2-5; IC 31-31-8-2
Affected: IC 31-31-8
Sec. 40.
(a) Written policy, procedure, and practice provide that a juvenile's health records, paper or electronic, or both, contain the following items, or documented attempts to obtain the following items, filed in a uniform manner: (1) Patient identification on each sheet.(2) Receiving screening form.(3) Health appraisal data and examination forms.(4) Record of immunizations.(5) Diagnoses, treatments, and dispositions.(6) Individualized treatment plan, when applicable.(8) Place, date, and time of health encounters.(9) Record of prescribed medications and their administration records, if applicable.(10) Laboratory, x-ray, and diagnostic studies.(11) Release of information forms.(12) Consent and refusal forms.(13) Health services reports, including the following: (A) Emergency department.(14) Discharge summary of hospitalization and other termination summaries, including the following: (A) Outpatient treatments.(B) Special services not requiring hospitalization but which have an endpoint that is documented.(15) Legible signatures and the titles of the providers in ink, type, or stamp under the signature.(b) The health care authority approves the: (1) method of recording entries in the records;(2) form and format of the records; and(3) procedures for record maintenance and safekeeping.(c) The health record is made available to, and is used for documentation by, all qualified health care professionals and health care practitioners.Department of Correction; 210 IAC 8-8-40; filed 9/16/2022, 3:13 p.m.: 20221012-IR-210220072FRA