37.98.701    YOUTH CASE RECORDS

(1) A program shall maintain a written case record for each youth which must include administrative, treatment and educational data from the time of the youth's admission until the time the youth leaves the program. A youth's case record must include the following:

(a) the name, sex and birth date of the youth;

(b) the name, address and telephone number of the parent(s) or guardian of the youth;

(c) date of admission and placing agency;

(d) if the youth was not living with his or her parents prior to admission, the name, address, telephone number and relationship to the youth of the person with whom the youth was living;

(e) all documents related to the referral of the youth to the program as provided by the placing agency;

(f) documentation of the current custody and legal guardianship as provided by the placing agency;

(g) the youth's court status, if applicable;

(h) consent forms signed by the parents or guardian prior to placement that allow the program to authorize all necessary medical care, routine tests, immunization and emergency medical or surgical treatment;

(i) health records including medical history and vaccination record as provided by the placing agency;

(j) education records and reports;

(k) treatment or clinical records and reports;

(l) records of special or serious incidents;

(m) case plans and related material;

(n) social summary current to date of placement;

(o) report stating reason for placement;

(p) quarterly progress reports on the youth's reaction to the placement and services provided;

(q) date of discharge, reason for discharge, and the name, telephone number and address of the person or agency to whom the youth was discharged; and

(r) all other youth records and documentation as required by these rules.

History: Sec. 50-5-220, MCA; IMP, Sec. 50-5-220, MCA; NEW, 2004 MAR p. 1960, Eff. 8/6/04.