Current through Register Vol. 24-18, September 15, 2024
(1) Any identifying and personal information
about a child and the child's family must be kept confidential as required by
chapter
26.33 RCW. These records
must be kept in a secure place inaccessible to clients, unauthorized staff and
the public.
(2) During a child's
placement, the child's record must be kept secure at the site. Your facility
must attempt to obtain the following information for the child's record, as
appropriate to your program:
(a) The child's
name, birth date, and legal status;
(b) Name and telephone number of the child's
DSHS worker and/or case manager for each child in care, if
appropriate;
(c) Written consent,
if any, for providing medical care and emergency surgery (unless that care is
authorized by a court order);
(d)
Names, addresses, and telephone numbers of persons authorized to take the child
in care out of the facility;
(e)
Copies of the current legal authority to place, if any;
(f) Current case plans;
(g) Social summary;
(h) Documentation of a child's treatment
provided by your staff with the signature of the person making the entry to the
progress notes;
(i) Information
related to suspected child abuse and/or neglect referrals made to children's
administration, including the concern, date and person taking the
report;
(j) Intake procedures
completed including an assessment of the youth's likelihood to stay in your
facility;
(k) Date and time of
Orientation;
(l) A log and written
report that identifies all incidents requiring physical restraints for a
child;
(m) Any incident reports
involving youth; and
(n) A copy of
any discharge summaries and family assessments in the child's case
record.
(3) In addition,
your records must contain the following information if available:
(a) Names, address and telephone numbers of
parents or persons to be contacted in case of emergency;
(b) Information on specific cultural needs of
the child;
(c) Medical history
including any medical problems, name of doctor, type of medical coverage and
provider, date of any illnesses or accidents while at the facility;
(d) Mental health history and any current
mental health, chemical dependency, and behavioral issues, including medical
and psychological reports when available;
(e) Other pertinent information related to
the child's health, including basic medical information, such as current
prescription medications, immunizations, allergies, dental records and/or eye
exams;
(f) Child's school records,
report cards, school pictures, and Individual Education Plans (IEP);
(g) Special instructions including
supervision requirements and suggestions for managing problem
behavior;
(h) Inventory of the
child's personal belongings at the time of placement;
(i) Approved list of individuals the child
may have contact with;
(j) The
child's visitation plan; and
(k)
For pregnant and parenting youth, information on the mother/father of the
youth's child, if available.
(4) If a child's placement extends beyond
seventy-two hours, you must obtain the child's immunization records. If the
child is not current with immunizations, they must be updated as soon as
medically possible. Immunization records are not required to be current for
children placed in:
(a) Interim
facilities;
(b) Group receiving
centers; or
(c) Crisis residential
centers.
(5) If you are
unable to obtain this information from the department you must document your
attempt to obtain the requested information in the child's file.
