10A NCAC 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.

History Note:        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.