(1) Any identifying and personal information about a child and the child's family must be kept confidential as required by chapter 26.33 RCW. These records must be kept in a secure place inaccessible to clients, unauthorized staff and the public.

(2) During a child's placement, the child's record must be kept secure at the site. Your facility must attempt to obtain the following information for the child's record, as appropriate to your program:

(a) The child's name, birth date, and legal status;

(b) Name and telephone number of the child's DSHS worker and/or case manager for each child in care, if appropriate;

(c) Written consent, if any, for providing medical care and emergency surgery (unless that care is authorized by a court order);

(d) Names, addresses, and telephone numbers of persons authorized to take the child in care out of the facility;

(e) Copies of the current legal authority to place, if any;

(f) Current case plans;

(g) Social summary;

(h) Documentation of a child's treatment provided by your staff with the signature of the person making the entry to the progress notes;

(i) Information related to suspected child abuse and/or neglect referrals made to children's administration, including the concern, date and person taking the report;

(j) Intake procedures completed including an assessment of the youth's likelihood to stay in your facility;

(k) Date and time of orientation;

(l) A log and written report that identifies all incidents requiring physical restraints for a child;

(m) Any incident reports involving youth; and

(n) A copy of any discharge summaries and family assessments in the child's case record.

(3) In addition, your records must contain the following information if available:

(a) Names, address and telephone numbers of parents or persons to be contacted in case of emergency;

(b) Information on specific cultural needs of the child;

(c) Medical history including any medical problems, name of doctor, type of medical coverage and provider, date of any illnesses or accidents while at the facility;

(d) Mental health history and any current mental health, chemical dependency, and behavioral issues, including medical and psychological reports when available;

(e) Other pertinent information related to the child's health, including basic medical information, such as current prescription medications, immunizations, allergies, dental records and/or eye exams;

(f) Child's school records, report cards, school pictures, and individual education plans (IEP);

(g) Special instructions including supervision requirements and suggestions for managing problem behavior;

(h) Inventory of the child's personal belongings at the time of placement;

(i) Approved list of individuals the child may have contact with;

(j) The child's visitation plan; and

(k) For pregnant and parenting youth, information on the mother/father of the youth's child, if available.

(4) If a child's placement extends beyond seventy-two hours, you must obtain the child's immunization records. If the child is not current with immunizations, they must be updated as soon as medically possible. Immunization records are not required to be current for children placed in:

(a) Interim facilities;

(b) Group receiving centers; or

(c) Crisis residential centers.

(5) If you are unable to obtain this information from the department you must document your attempt to obtain the requested information in the child's file.