24.2  Medical Information to be Obtained when Child Enters Care

1. The Children’s Service Worker (CSW) will ensure that initial medical information is obtained from the parent/physician and given to the foster parent within 72 hours, if possible, but no later than 30 days following placement.  This information should include:
   1. Immunization history;
   2. Past and current medical problems;
   3. Allergies and adverse reactions to medications;
   4. Hospitalizations and surgeries;
   5. Dental records;
   6. Current medications;
   7. Current and past medical providers;
   8. Developmental milestones;
   9. Prenatal and birth history;
   10. Current and past illnesses;
   11. Psychological services - past and current;
   12. Nutritional history;
   13. Environmental issues which may pose health risk, i.e., exposure to lead;
   14. Mother's use of alcohol/drugs during pregnancy; and
   15. Risk factors contributing to potential exposure to HIV/AIDS.
2. The Children’s Service Worker shall establish and maintain a medical record (separate and distinct section in the file or separate record) on each child in care.  In order to ensure continuity of care, this record shall include copies of the initial medical examination report and ALL existing medical records on the child, including both current and past medical information.

Also included in the medical record should be a copy of the log of illnesses, medications and the amount given, visits to physician/therapist and the purpose of the visit.  The medical log should be kept by the placement provider and submitted to the Children’s Service Worker for inclusion in the child's record on a monthly basis.

Related Subject:  Section 5 Chapter 1 Documentation and Record Maintenance

3. A summary of the child's medical history including any recent illnesses, and the name and dosage of medication currently taken by the child shall be passed on to the new resource, in writing, whenever a change in placement occurs.
4. The initial health examination shall occur within 24 hours of the child coming into care.  If possible, this initial examination should be a complete Healthy Children and Youth (HCY) screening (physical, eye, hearing, dental examinations).  If only a partial screening (physical examination) can be completed within 24 hours, eye, hearing and dental examinations shall occur within the first 30 days the child is in care.
5. Ongoing medical care should be obtained in accordance to the HCY examination/immunization schedule.
6. All information about the child's medical care while in out-of-home care shall be shared with the parent/caregiver on an ongoing basis.  A copy of the complete medical history should be furnished to the parent/guardian.
7. The Children's Service Worker (CSW) shall ensure children receive sexual health education including information on sexually transmitted diseases and birth control appropriate to their individual age and physical and emotional maturity. The CSW should make extensive efforts to involve the parent/s in sexual health decisions and encourage the child to discuss these matters with his his/her parent/s when circumstances allow. When attempts to involve the parents have been unsuccessful and/or parental consent cannot be obtained, the CSW should involve the Family Support Team (FST). If the FST reaches a conclusion inconsistent with the wishes of the parent/s the CSW should seek court approval for the child to use birth control. The CSW shall not in any circumstance give verbal or written consent for a child to receive birth control without the approval of the parent, the parent and FST, or the Court. All efforts to comply with this policy must be clearly documented in the record. Directives given by the Court to handle birth control consent or sexual health decisions contrary to this policy should be followed and documented in the record.
8. In order to prevent further spread, unnecessary avoidance, and embarrassment, resources and information shall be made available to all parties involved with children that have communicable diseases, parasites, sexually transmitted diseases or test positive for HIV exposure.
9. The Children’s Service Worker shall ensure that children with serious emotional and behavior disturbances receive appropriate counseling, therapy and/or medication.  Also, the Worker must ensure that the placement provider has the knowledge and skills necessary to provide appropriate care for the child.

Chapter Memoranda History: (prior to 1/31/07)

CD04-83, CD05-05, CD05-48, CD05-50, CD05-51, CD06-76

Memoranda History:

CD08-47