10A NCAC 09 .2409         CHILDREN'S RECORDS

(a)  In addition to all other children's records required in G.S. 110 and this Chapter, the following shall be completed for the children admitted to the mildly sick area:

(1)           Preadmission health assessment which includes documentation of health status, current symptoms, baseline temperature and respiratory rate, and any medications administered in the last 24 hours;

(2)           General admission information which includes information about the child's typical behavior, activity level, patterns of eating, sleeping, and toileting;

(3)           An individualized plan of care describing how the child's needs shall be met, based upon Subparagraphs (a)(1) and (a)(2) of this Rule, shall be developed by the parent and a staff member who has completed training described in Subparagraph (a)(3) of Rule .2408 of this Section; and

(4)           A daily written record shall be maintained and a copy given to parents of the child's eating, sleeping, and toileting patterns; medications administered; activity levels; changes in symptoms; and any additional information that the provider deems relevant such as child's temperament.

(b)  All records shall be on file in the mildly sick area prior to admittance of the mildly sick child to the mildly sick area. If a child is enrolled in the well child care component of a child care center, records may be maintained in the well child care area, along with a copy of the child's enrollment application as required in Rule .0801 of this Chapter. The records specified in Subparagraphs (a)(1) through (a)(4) of this Rule shall be kept in the mildly sick area.

History Note:        Authority G.S. 110-88(11); 143B-168.3;

Eff. April 1, 2003;

Readopted Eff. October 1, 2017.