Compilation of Rules and Regulations of the State of Georgia
Department 290 - RULES OF DEPARTMENT OF HUMAN SERVICES
Chapter 290-2 - FAMILY AND CHILDREN SERVICES
Subject 290-2-29 - RULES AND REGULATIONS FOR MATERNITY HOMES
Rule 290-2-29-.12 - Maintenance of Case Records

Universal Citation: GA Rules and Regs r 290-2-29-.12

Current through Rules and Regulations filed through September 23, 2024

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

(a) Completed application for admission and services with identifying information that includes, but is not limited to, name, birth date, age, race, marital status, religion;

(b) Date of admission and source of referral including all documents related to the referral and admission of the resident to the home;

(c) Name, address, and telephone numbers of the parent(s) or legal guardian(s) or legal representative(s) of the resident;

(d) Assessment of services needed;

(e) Case plan or out-of-home family services agreement;

(f) Documentation of case reviews and updates of case plan;

(g) Educational and vocational information;

(h) Authorization for medical care, if resident is a minor;

(i) Medical and obstetrical history and examination completed no more than seven (7) days prior to or seven (7) days following admission to the home;

(j) Record of medical and dental services received;

(k) Medical records, including documentation of visits to physicians and dentists, records of prescriptions and administration of medicines, immunization records, and orders for modified diets;

(l) Authorization for receiving or sending information concerning the resident;

(m) Correspondence and contacts with other persons or agencies concerning the resident;

(n) Copy of financial agreements;

(o) Copy of any agreement with a transitional agency, entity or person providing services to the resident, such as a child placing agency, adoption agency or attorney;

(p) Approved 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 home shall maintain documentation of resident's adherence to and the home's oversight of the visitation and contact plans;

(q) Documentation of hospital care and delivery dates;

(r) Name of baby and sex;

(s) A record of birth including birth date, weight at birth, measurements, any birth defects, method of delivery, and complications of pregnancy and delivery;

(t) Name, address, and title of person and/or agency to whom baby discharged, if not to mother;

(u) Date, time and circumstances of discharge from the home and the resident's plan for herself and baby; and relationship and signature of the individual to whom the resident was discharged, if a minor; and

(v) Signed acknowledgement of resident's rights.

O.C.G.A. Secs. 49-5-3, 49-5-8, 49-5-12

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