Section 441.105.17. Case files.

         105.17(1) Generally. For the purpose of promoting a uniformity of program for all facilities and as an aid to the department of human services in determining its approval of a facility all facilities shall establish and maintain for inspection case files on each child.

         105.17(2) Face sheet. For all children, a face sheet containing the following information shall be completed.

            a.                Full name, current address, and date of birth.

            b.                Parent’s(s’) full name(s).

            c.                Parent’s(s’) address and telephone number.

            d.                Religious preference of the child and also parent, if available.

            e.                Statement of who has legal custody and guardianship.

            f.                 Name of referring worker and agency making the referral.

            g.                Telephone number and address of referring agency or court.

            h.                Name, address, and telephone number of the child’s attorney.

         105.17(3) Written summary. When a written summary has been requested under 441—105.12(232), a copy shall be placed in the child’s record.

         105.17(4) Documentation. The following information shall be documented in each child’s record:

            a.                Appropriate notes on all significant contacts by staff with parents, referral person and other collateral contacts.

            b.                A summary related to discharge including name, address, and relationship of person to whom discharged.

         105.17(5) Other information. The following information shall be requested when the child remains in the facility more than four days and, when available, shall be placed in the child’s record.

            a.                Current family history or social history.

            b.                Case plans submitted by the referring agency or orders of the court.

            c.                Psychological and psychiatric records; copies of all available testing performed plus notes and records of contact with the child.

            d.                Medical.

             (1)              A record of all illnesses, immunizations, communicable diseases and follow-up treatment.

             (2)              Medical and surgical releases or authorizations signed by the parent, guardian, custodian or court, including releases or authorizations for anesthesia and emergency medical and surgical treatment.

             (3)              A record of all medical and dental examinations, including findings.

             (4)              Date of last physical examination prior to placement.

            e.                School.

             (1)              Name and address of school attended.

             (2)              Grade placement.

             (3)              Current school in which child is enrolled.

             (4)              Specific educational problems.

             (5)              Remedial action.

            f.                 Placement agreement, court order, and other releases and authorizations.

             (1)              An agreement authorizing the facility to accept the child.

             (2)              An agreement setting forth the terms of payment for care.

             (3)              Other releases and authorizations applicable to the placement.

             (4)              All court orders affecting the custody or guardianship of the child.

[ ARC 2743C , IAB 10/12/16, effective 12/1/16]