10A N.C. Admin. Code 70K.0203

Current through Register Vol. 39, No. 12, December 1, 2024

Section 70K .0203 - CASE RECORD

A confidential case record shall be maintained for each resident which includes:

(1) a completed application for admission and services with identifying information about the resident;

(2) a summary of the referral source, background information about the resident, and an assessment of the services needed;

(3) a complete medical and obstetrical history and examination before or within one week after admission to the home;

(4) record of medical and dental services received;

(5) authorization for medical care for minors;

(6) authorization for receiving or sending information concerning the resident;

(7) copy of financial agreements;

(8) a copy of the agreement with the licensed child placing agency or county department of social services providing services to the resident;

(9) case plan or out-of-home family services agreement;

(10) visitation and contact plan including type, duration, location both on-site and off-site, and frequency, as well as any rationale for restrictions on family involvement; the facility shall maintain documentation of all family time;

(11) date of admission to the maternity home and documentation of services provided including hospital care and delivery dates;

(12) date, time and circumstances of discharge from the maternity home and the resident's plans for herself and baby; and in the case of minors the name, relationship and signature of the individual the resident was released to;

(13) correspondence and contacts with other persons or agencies concerning the resident; and

(14) signed acknowledgement of client rights.

10A N.C. Admin. Code 70K .0203

Authority G.S. 131D-1; 143B-153;
Eff. February 1, 1986;
Amended Eff. October 1, 2008;
Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. April 5, 2016.

Authority G.S. 131D-1; 143B-153;
Eff. February 1, 1986;
Amended Eff. October 1, 2008.