Cal. Code Regs. tit. 15 § 1406

Current through Register 2024 Notice Reg. No. 24, June 14, 2024

Section 1406 - Health Care Records

In juvenile facilities providing on-site health care, the health administrator, in cooperation with the facility administrator, shall maintain individual and dated health records that include when applicable, 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;

(m) laboratory reports; and,

(n) individual treatment plan.

Written policy and procedures shall provide for maintenance of the health record in a locked area or secured electronically, separate from the confinement record. Access to the medical and/or behavioral/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.

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

Cal. Code Regs. Tit. 15, § 1406

1. New section filed 3-6-97; operative 4-5-97 (Register 97, No. 10).
2. Amendment of first paragraph, subsections (l)-(m), new subsection (n) and amendment of penultimate paragraph filed 11-14-2018; operative 1-1-2019 (Register 2018, No. 46).

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.

1. New section filed 3-6-97; operative 4-5-97 (Register 97, No. 10).
2. Amendment of first paragraph, subsections (l )-(m), new subsection (n) and amendment of penultimate paragraph filed 11-14-2018; operative 1/1/2019 (Register 2018, No. 46).