North Carolina Administrative Code
Title 10A - HEALTH AND HUMAN SERVICES
Chapter 70 - CHILDREN'S SERVICES
Subchapter J - MINIMUM LICENSING STANDARDS FOR SPECIALIZED RESIDENTIAL CHILD CARE PROGRAMS
Section .0200 - EMERGENCY SHELTER CARE PROGRAM
Section 70J .0204 - RECORDKEEPING

(1) written consent for placement;

(2) documentation of placement authority;

(3) completed application for services that includes demographic information on the child and the child's family;

(4) consents for release of information, emergency medical treatment, family time/visitation;

(5) a medical examination report completed within two weeks after admission unless the child's health status indicates the completion of a medical examination report sooner and copies of subsequent medical examination reports;

(6) medical records and immunization records;

(7) intake study and related documents;

(8) out-of-home family services agreement and biweekly reviews;

(9) family contact and visitation 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;

(10) birth certificate or other documentation that verifies the child's birth;

(11) court orders;

(12) documentation of medical insurance;

(13) consents for time-limited, audio-visual recording signed by both the child and parent or guardian , or legal custodian;

(14) progress notes; and

(15) discharge summary including date of discharge, time of discharge and the name, address, telephone number, and relationship of the person or agency to whom the child was discharged, a summary of services provided during care, needs which remain to be met and plans for the services needed to meet these goals.