La. Admin. Code tit. 48 § I-7861

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

Section I-7861 - Patient Records

A. Retention of Patient Records

1. The clinic shall establish and maintain a medical record on each patient. The record shall be maintained to assure that the medical treatment of each patient is completely and accurately documented, records are readily available and systematically organized to facilitate the compilation and copying of such information.

a. Safeguards shall be established to maintain confidentiality and protection of the medical record, whether stored electronically or in paper form, from fire, water, or other sources of damage and from unauthorized access.

2. The department shall have access to all business records, patient records or other documents maintained by or on behalf of the clinic to the extent necessary to ensure compliance with this Chapter.

a. Ensuring compliance includes, but is not limited to:

i. permitting photocopying of records by the department; and

ii. providing photocopies to the department of any record or other information the department may deem necessary to determine or verify compliance with this Chapter.

3. Patient records shall be kept for a period of six years from the date a patient is last treated by the clinic. The patient records shall:

a. remain in the custody of the clinic, whether stored in paper form or electronically, in clinic or off-site; and

b. be readily available to department surveyors as necessary and relevant to complete licensing surveys or investigations.

c. Repealed.

B. Content of Medical Record

1. A medical record shall include, but is not limited to, the following data on each patient:

a. patient identification information;

b. medical and social history, including results from an inquiry to the Prescription Monitoring Program (PMP), if any;

c. physical examination;

d. chief complaint or diagnosis;

e. clinical laboratory reports, including drug screens, if any;

f. pathology report (when applicable), if any;

g. physicians orders;

h. radiological report (when applicable), if any;

i. consultation reports (when applicable), if any;

j. current medical and surgical treatment, if any;

k. progress or treatment notes;

l. nurses' notes of care, if any, including progress notes and medication administration records;

m. authorizations, consents, releases, and emergency patient or family contact number;

o. special procedures reports, if any;

p. an informed consent for chronic pain narcotic therapy; and

q. an agreement signed by the patient stating that he/she:

i. has been informed and agrees to obtain and receive narcotic prescriptions only from the licensed pain management clinic where he is receiving treatment for chronic pain;

ii. shall be subject to quarterly, periodic, unannounced urine drug screens;

iii. shall not participate in diversion of any controlled dangerous substance or narcotic medications, or both;

iv. shall not participate in illicit drug use; and

v. acknowledges that non-compliance with this agreement may be a reason for the clinic's refusal to treat.

2. An individualized treatment plan shall be formulated and documented in the patient's medical record. The treatment plan shall be in accordance with the board's pain rules and shall include, but is not limited to, the following:

a. medical justification for chronic pain narcotic therapy;

b. documentation of other medically reasonable alternative treatment for relief of the patient's pain have been considered or attempted without adequate or reasonable success; and

c. the intended prognosis of chronic pain narcotic therapy which shall be specific to the individual medical needs of the patient.

3. Signatures. Clinical entries shall be signed by a physician, as appropriate, i.e., attending physician, consulting physician, anesthesiologist, pathologist, etc. Nursing progress notes and assessments shall be signed by the nurse.

4. Progress Notes. All pertinent assessments, treatments and medications given to the patient shall be recorded in the progress notes. All other notes, relative to specific instructions from the physician, shall also be recorded.

5. Completion of the medical record shall be the responsibility of the patient's physician.

C. Provided the regulations herein are met, nothing in this Section shall prohibit the use of automated or centralized computer systems, or any other electronic or non-electronic techniques used for the storage of patient medical records.

La. Admin. Code tit. 48, § I-7861

Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 34:86 (January 2008), Amended by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 41:2652 (December 2015).

AUTHORITY NOTE: Promulgated in accordance with R.S. 40.2198.11-13.