La. Admin. Code tit. 48 § I-5269

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

Section I-5269 - Record Keeping

A. Medical Records. A medical record shall be developed at the time the child is accepted at the PDHC facility and maintained throughout the facility's care of the child.

1. The record shall be signed by authorized personnel and shall contain at least the following documents:

a. a medical plan of treatment and a nursing plan of care;

b. the referral and admission documents concerning the child;

c. physician orders;

d. medical history, including allergies and special precautions;

e. documentation of immunizations;

f. medication/treatment administration record;

g. concise, accurate information and initialed case notes reflecting progress toward achievement of care goals or reasons for lack of progress;

h. documentation of nutritional management and therapeutic diets, as appropriate;

i. documentation of physical, occupational, speech and other special therapies;

j. correspondence and other documents concerning the child;

k. an order written by the prescribing physician if the child terminates services with the facility, if applicable; and

l. a summary, including the reason why the child is terminating services with the facility, if applicable.

2. The medical records shall contain the individualized nursing care plan that shall be developed within 10 working days of the child's acceptance to the PDHC facility.

a. The nursing care plan shall be reviewed and revised quarterly, or more frequently as necessary. The nursing care plan shall include any recommendations and revisions to the care plan based on consultation with other professionals involved in the child's care.

3. The plan of care, telephone and/or verbal orders shall be signed by the physician within a timely manner, not to exceed 30 days.

a. The physician's verbal orders may be accepted by a registered nurse, a qualified therapist or a licensed practical nurse as authorized by state and federal laws and regulations.

b. Verbal orders taken by an LPN shall be cosigned by an RN or appropriate therapist.

c. Electronic physician signatures may be accepted per PDHC facility policies.

d. Stamped physician signatures shall not be accepted.

4. All medical and patient records shall be maintained by the PDHC facility in accordance with federal and state law,rule, and regulation regarding confidentiality, privacy and retention.

B. Personnel Records. Personnel records shall be kept in a place, form and system in accordance with appropriate medical and business practices. All personnel records shall be available in the facility for inspection by the department during normal business hours. These records shall be maintainted in accordance with federal and state laws, rules, and regulations.

La. Admin. Code tit. 48, § I-5269

Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 35:2775 (December 2009).

AUTHORITY NOTE: Promulgated in accordance with R.S. 40:2193-40:2193.4.