Health Care Record
Yes. The Individual Health Care Record is the youth-specific unified, organized collection of health records (i.e. histories, assessments, treatments, diagnostic tests, reports of consultations, etc.), which relate to a youth’s medical, mental/behavioral, and dental health. It is essential that a comprehensive, organized and accurate Individual Health Care Record is developed and maintained for each youth to facilitate effective communication among the various health care providers who treat each individual youth.
Yes. All on-site medical health care encounters, including those performed by licensed health care professionals, health care para-professionals, and other trained facility staff shall be documented in the chronological progress notes in chronological order (with exceptions as noted in Chapter 15). Any person, licensed or non-licensed, administering medication and/or treatment to a youth must document on the Medication and Treatment Record (MAR) any medications, physical or dental health treatment provided pursuant to physician’s orders. Any medications administered outside of scheduled sick call shall be documented accordingly on the MAR as well.
If duplicate identical copies of a document (i.e., the Health Related History or Comprehensive Physical Assessment) exist in a youth’s Individual Health Care Record; the replicates may be shredded as long as they contain the exact same information as the copy that remains in the youth’s record.