83 Neb. Admin. Code, ch. 6, § 013

Current through September 17, 2024

Section 83-6-013 - Medical Files

The facility shall maintain a separate file for each juvenile's medical records. The medical file shall contain, at a minimum, the following:

013.01 Medical screening form;

013.02 Any mental health screening form;

013.03 Any subsequent health appraisal forms;

013.04 Any requests for medical attention;

013.05 All records of medical encounters, including time, date and provider of the services;

013.06 All findings, diagnoses, and treatments;

013.07 Copy of all prescriptions and records of dispensing;

013.08 Any release of medical information forms completed; and

013.09 Any consent or refusal of medical services forms completed.

83 Neb. Admin. Code, ch. 6, § 013