§ 1406. Health Care Records.

In juvenile facilities providing on-site health care, the health administrator, in cooperation with the facility administrator, shall maintain complete individual and dated health records that include, but are not limited to:

(a) intake health screening form;

(b) health appraisals/medical examinations;

(c) health service reports (e.g., emergency department, dental, psychiatric, and other consultations);

(d) complaints of illness or injury;

(e) names of personnel who treat, prescribe, and/or administer/deliver prescription medication;

(f) location where treatment is provided;

(g) medication records in conformance with Title 15, Section 1438;

(h) progress notes;

(i) consent forms;

(j) authorizations for release of information;

(k) copies of previous health records;

(l) immunization records; and,

(m) laboratory reports.

Written policy and procedures shall provide for maintenance of the health record in a locked area separate from the confinement record. Access to the medical/mental health record shall be controlled by the health administrator and shall assure that all confidentiality laws related to the provider-patient privilege apply to the health record. Minors shall not be used to translate confidential medical information for other non-English speaking minors.

Health care records shall be retained in accordance with community standards.

HISTORY

1. New section filed 3-6-97; operative 4-5-97 (Register 97, No. 10).

Note

Note: Authority cited: Sections 210 and 885, Welfare and Institutions Code; and Assembly Bill 1397, Chapter 12, Statutes of 1996. Reference: 1995-96 Budget Act, Chapter 303, Item Number 5430-001-001, Statutes of 1995; Assembly Bill 904, Chapter 304, Statutes of 1995; and Assembly Bill 1397, Chapter 12, Statutes of 1996.