A confidential case record shall be maintained for each resident which includes:

1. (1) a completed application for admission and services with identifying information about the resident;
2. (2) a summary of the referral source, background information about the resident, and an assessment of the services needed;
3. (3) a complete medical and obstetrical history and examination before or within one week after admission to the home;
4. (4) record of medical and dental services received;
5. (5) authorization for medical care for minors;
6. (6) authorization for receiving or sending information concerning the resident;
7. (7) copy of financial agreements;
8. (8) a copy of the agreement with the licensed child placing agency or county department of social services providing services to the resident;
9. (9) case plan or out-of-home family services agreement;
10. (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. (11) date of admission to the maternity home and documentation of services provided including hospital care and delivery dates;
12. (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. (13) correspondence and contacts with other persons or agencies concerning the resident; and
14. (14) signed acknowledgement of client rights.

History Note: 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.