La. Admin. Code tit. 48 § I-4233

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-4233 - Participant Case Records

A. A center shall have an organized record system which includes a written case record for each participant. The case record shall contain administrative and treatment data from the time of admission until the time that the participant leaves the center.

B. The participant's case record shall include:

1. identifying information such as:

a. name;

b. birth date;

c. home address;

d. Social Security number;

e. marital status;

f. gender;

g. ethnic group; and

h. religion;

2. identifying information for the participant's personal representative, if applicable, such as:

a. name;

b. address; and

c. telephone number;

3. social and medical history including:

a. a complete record of admitting diagnoses and any treatments that the participant is receiving;

b. history of serious illness, serious injury or major surgery;

c. allergies to medication;

d. a list of all prescribed medications and non-prescribed drugs currently used;

e. current use of alcohol; and

f. the name of the participant's personal physician and an alternate;

4. complete health records, when available, including physical, dental and/or vision examinations;

5. a copy of the participant's individual service plan including:

a. any subsequent modifications; and

b. an appropriate summary to guide and assist direct care staff in implementing the participant's program;

6. the findings made in periodic reviews of the plan including:

a. a summary of the successes and failures of the participant's program; and

b. recommendations for any modifications deemed necessary;

7. any grievances or complaints filed by the participant and the resolution or disposition of these grievances or complaints;

8. a log of the participant's attendance and absence;

9. a physician's signed and dated orders for medication, treatment, diet, and/or restorative and special medical procedures required for the safety and well-being of the participant;

10. progress notes that:

a. document the delivery of all services identified in the individualized service plan;

b. document that each staff member is carrying out the approaches identified in the individualized service plan that he/she is responsible for;

c. record the progress being made and discuss whether or not the approaches in the individualized service plan are working;

d. record any changes in the participant's medical condition, behavior or home situation which may indicate a need for a change in the individualized service plan; and

e. document the completion of incident reports, when appropriate; and

NOTE: Each individual responsible for providing direct services shall record progress notes at least weekly, but any changes to the participant's condition or normal routine should be documented on the day of the occurrence.

11. discharge planning and referral.

11.a. - 12. Repealed.

C. All entries made by center staff in participants' records shall be legible, signed and dated.

D. The medications and treatments administered to participants at the center shall be charted by the appropriate staff.

E. The center may produce, maintain and/or store participant case records either electronically or in paper form.

F. The center shall ensure that participant case records are available to staff who are directly involved with participant care.

La. Admin. Code tit. 48, § I-4233

Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 34:2183 (October 2008), repromulgated LR 34:2629 (December 2008), Amended by the Department of Health, Bureau of Health Services Financing, LR 431972 (10/1/2017).

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and 40:2120.41-46.