8.7 Health Care Records Pursuant to Section 1406

Chapter 8
Section 8.7
Subject 8.7 Health Care Records Pursuant to Section 1406
Effective Date 2/1/2024 12:00 AM
  1. The Health Administrator, in cooperation with the Facility Administrator, shall maintain complete individual and dated health records that include when applicable, but is not limited to:
    1. Intake health screening form.
    2. Medical examinations.
    3. Health service reports.
    4. Complains of illness or injury.
    5. Names of health personnel, who treat, prescribe, administer, or deliver mediation.
    6. Location treatment provided.
    7. Medications records (see Section 1438, 1439)
    8. Progress notes.
    9. Consent forms.
    10. Authorizations for release of information.
    11. Copies of previous health records.
    12. Immunization records.
    13. Laboratory reports
    14. Individual treatment plan
  2. Maintenance
    1.  Health records shall be maintained in a locked area separate from the confinement record, or secured electronically.
    2. Access to health behavioral/mental health records shall be authorized by the Health Administrator.
    3. Youth shall not be used to translate confidential medical information for other non-English speaking youth.
    4. Health care records shall be retained in accordance with community standards.