83 Neb. Admin. Code, ch. 6, § 013

013 Medical Files. The facility shall maintain a separate file for each juvenile's medical records. The medical file shall contain, at a minimum, the following: 013.01 Medical screening form; 013.02 Any mental health screening form; 013.03 Any subsequent health appraisal forms; 013.04 Any requests for medical attention; 013.05 All records of medical encounters, including time, date and provider of the services; 013.06 All findings, diagnoses, and treatments; 013.07 Copy of all prescriptions and records of dispensing; 013.08 Any release of medical information forms completed; and 013.09 Any consent or refusal of medical services forms completed.