Rule 290-2-29-.12. Maintenance of Case Records

1. (1) A confidential case record shall be maintained for each resident which includes:

   1. (a) Completed application for admission and services with identifying information that includes, but is not limited to, name, birth date, age, race, marital status, religion;
   2. (b) Date of admission and source of referral including all documents related to the referral and admission of the resident to the home;
   3. (c) Name, address, and telephone numbers of the parent(s) or legal guardian(s) or legal representative(s) of the resident;
   4. (d) Assessment of services needed;
   5. (e) Case plan or out-of-home family services agreement;
   6. (f) Documentation of case reviews and updates of case plan;
   7. (g) Educational and vocational information;
   8. (h) Authorization for medical care, if resident is a minor;
   9. (i) Medical and obstetrical history and examination completed no more than seven (7) days prior to or seven (7) days following admission to the home;
   10. (j) Record of medical and dental services received;
   11. (k) Medical records, including documentation of visits to physicians and dentists, records of prescriptions and administration of medicines, immunization records, and orders for modified diets;
   12. (l) Authorization for receiving or sending information concerning the resident;
   13. (m) Correspondence and contacts with other persons or agencies concerning the resident;
   14. (n) Copy of financial agreements;
   15. (o) Copy of any agreement with a transitional agency, entity or person providing services to the resident, such as a child placing agency, adoption agency or attorney;
   16. (p) Approved 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 home shall maintain documentation of resident's adherence to and the home's oversight of the visitation and contact plans;
   17. (q) Documentation of hospital care and delivery dates;
   18. (r) Name of baby and sex;
   19. (s) A record of birth including birth date, weight at birth, measurements, any birth defects, method of delivery, and complications of pregnancy and delivery;
   20. (t) Name, address, and title of person and/or agency to whom baby discharged, if not to mother;
   21. (u) Date, time and circumstances of discharge from the home and the resident's plan for herself and baby; and relationship and signature of the individual to whom the resident was discharged, if a minor; and
   22. (v) Signed acknowledgement of resident's rights.

Authority: O.C.G.A. Secs. 49-5-3, 49-5-8, 49-5-12

History. Original Rule entitled "Maintenance of Case Records" adopted. F. Dec. 15, 2011; eff. Jan. 4, 2012.