North Carolina Administrative Code
Title 10A - HEALTH AND HUMAN SERVICES
Chapter 70 - CHILDREN'S SERVICES
Subchapter K - RESIDENTIAL MATERNITY HOMES
Section .0200 - MINIMUM LICENSURE STANDARDS
Section 70K .0203 - CASE RECORD
Current through Register Vol. 39, No. 6, September 16, 2024
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.
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.