(a) A health record file on each youth shall be maintained at the facility or program where the youth is placed in a format approved by:

1. (1) The Department of Health; or
2. (2) Other health authority with oversight and in a manner that complies with state and federal privacy law.

(b) The health record shall contain, at a minimum, the following information:

1. (1) A health screen completed at the time the youth was received at the facility or program;

2. (2) A copy of the youth’s medical treatment plan, if any, including:

   1. (A) Diagnoses;
   2. (B) Orders for physical therapy;
   3. (C) Occupational therapy;
   4. (D) Prescription and over-the-counter medication;
   5. (E) Nutrition plans; and
   6. (F) Other medical intervention;
3. (3) All current pharmaceutical prescriptions and medication administration log;
4. (4) A log of place, date, and time of all health encounters;

5. (5) Health service reports, including:

   1. (A) Medical;
   2. (B) Dental;
   3. (C) Optometric; and
   4. (D) Psychiatric;
6. (6) All health appraisal data forms;
7. (7) All consent and refusal forms; and
8. (8) The signature and title of the documenter.