441—114.11(237) Case files.
	114.11(1) Generally. All facilities shall establish and maintain case files on each child. The case files shall include the following:
	114.11(2) Face sheet. The face sheet shall contain the following information:
	a. 	Full name, birth place and date of birth.
	b. 	Parents’ full name.
	c. 	Parents’ address and telephone number.
	d. 	Religious preference of parents and child.
	e. 	Statement of who has legal custody and guardianship.
	f. 	Name of the referring worker and agency making the referral.
	g. 	Telephone number and address of the agency or court making the referral and contact information of the child’s attorney or guardian ad litem.
	114.11(3) Referral packet. All of the information required in the referral packet shall be contained in the case record including a social history on the child, a copy of the child’s physical assessment and immunization history, psychological testing, when available, current educational information, psychiatric report, when available, and the referring agency’s case plan.
	114.11(4) Legal documents.
	a. 	Placement agreement signed by parent(s) or custodian of the child.
	b. 	Petitions and orders of the court regarding adjudication, custody, or guardianship.
	114.11(5) Psychiatric and psychological. Psychiatric and psychological reports, when available.
	114.11(6) Correspondence. Correspondence regarding the child.
	114.11(7) Medical.
	a. 	Medical and surgical authorizations signed by the parent(s), guardian, or contained in the court order.
	b. 	Record of medical care received while in the facility.
	c. 	Information on past medical history.
	114.11(8) School.
	a. 	Name of school currently attended.
	b. 	Grade placement.
	c. 	Any specific educational problem.
	d. 	Remedial action recommended.
	114.11(9) Service plan. Individual child service plan, quarterly update, and revisions of the service plan. The service plan shall be updated quarterly or any time upon receipt of a new case permanency plan or juvenile court services plan or as otherwise needed to address the changing needs of the child. Discharge summary completing the service plan information shall be completed upon a child’s discharge from placement.
	114.11(10) Documentation. The following information shall be documented in each child’s record.
	a. 	Appropriate notes, all significant contacts with parents, referring worker and other collateral contracts, as well as staff counseling with child and notations on behavior.
	b. 	A summary related to discharge including:
	(1)	The name, address and relationship of the person or agency to whom the child was released.
	(2)	The discharge summary (as included in the service plan).
	(3)	Final disposition of a child’s medications as applicable.
	(4)	Identification of who transported the child and destination postdischarge.
	114.11(11) Electronic records. An authorized representative of the department shall be provided unrestricted access to electronic records pertaining to the care provided to the residents, who are served as a result of a contract with the department, of the facility.
	a. 	If access to an electronic record is requested by the authorized representative of the department, the facility may provide a tutorial on how to use its particular electronic system or may designate an individual who will, when requested, access the system, respond to any questions or assist the authorized representative as needed in accessing electronic information in a timely fashion.
	b. 	The facility shall provide a terminal where the authorized representative may access records.
	c. 	If the facility is unable to provide direct print capability to the authorized representative, the facility shall make available a printout of any record or part of a record on request in a time frame that does not intentionally prevent or interfere with the department’s survey or investigation.
[ARC 4793C, IAB 12/4/19, effective 1/8/20; ARC 6962C, IAB 4/5/23, effective 6/1/23]