Section 350. Form and content of case record

A. In addition to the data required and the intake study, the record shall include a formal request for care or application and/or a copy of court commitment and/or entrustment agreement which shall include financial responsibility, consent for necessary medical and surgical treatment and hospitalization. An entrustment shall only be entered into after it has been determined that the placing person has legal authority to do so.

B. A record shall be kept of on-going medical information on the child which shall include:

1. Immunizations;

2. Dental examinations;

3. Reports of any illness or injury and treatment given;

4. Psychiatric examinations and treatment given, if any;

5. Use of drugs;

6. Routine physical examinations and other medical contacts.

C. The record shall include a summary of the child's progress. Where long term care is offered, these reports shall be recorded at least annually and shall include the following:

1. Reports of significant incidents, both positive and negative, and changes in the family situation;

2. Contact with parents;

3. School reports;

4. Future planning;

5. Summary of child's development.

D. All correspondence relevant to a child shall be kept in the record.

E. Each record shall have a face sheet bearing factual data and identifying information. The face sheet shall include the following:

1. Name;

2. Date and place of birth;

3. Sex;

4. Religion;

5. Race;

6. Names and addresses of parents, siblings, and other close relatives;

7. Guardianship and custody;

8. Date of admission;

9. Insurance policy numbers, Medicaid number; and

10. Name of caseworker and casework supervisor, if an agency placement.

Historical Notes

Derived from VR615-24-01 §VIE, eff. November 22, 1972; amended, eff. July 1, 1981, eff. February 1, 1984, eff. May 1, 1984, eff. July 1, 1984.

Statutory Authority

§§ 63.2-217 and 63.2-1734 of the Code of Virginia.