Indiana Administrative Code
Title 210 - DEPARTMENT OF CORRECTION
Article 8 - JUVENILE DETENTION FACILITIES
Rule 8 - Medical
Section 8-40 - Juvenile health records
Universal Citation: 210 IN Admin Code 8-40
Current through September 18, 2024
Authority: IC 11-8-2-5; IC 31-31-8-2
Affected: IC 31-31-8
Sec. 40.
(a) Written policy, procedure, and practice provide that a juvenile's health records, paper or electronic, or both, contain the following items, or documented attempts to obtain the following items, filed in a uniform manner:
(1) Patient identification on each
sheet.
(2) Receiving screening
form.
(3) Health appraisal data and
examination forms.
(4) Record of
immunizations.
(5) Diagnoses,
treatments, and dispositions.
(6)
Individualized treatment plan, when applicable.
(7) Progress reports.
(8) Place, date, and time of health
encounters.
(9) Record of
prescribed medications and their administration records, if
applicable.
(10) Laboratory, x-ray,
and diagnostic studies.
(11)
Release of information forms.
(12)
Consent and refusal forms.
(13)
Health services reports, including the following:
(A) Emergency department.
(B) Dental.
(C) Mental health.
(D) Telemedicine.
(E) Other consultations.
(14) Discharge summary of hospitalization and
other termination summaries, including the following:
(A) Outpatient treatments.
(B) Special services not requiring
hospitalization but which have an endpoint that is
documented.
(15) Legible
signatures and the titles of the providers in ink, type, or stamp under the
signature.
(b) The health care authority approves the:
(1) method of
recording entries in the records;
(2) form and format of the records;
and
(3) procedures for record
maintenance and safekeeping.
(c) The health record is made available to, and is used for documentation by, all qualified health care professionals and health care practitioners.
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