La. Admin. Code tit. 48 § I-6251

Current through Register Vol. 50, No. 9, September 20, 2024

Section I-6251 - Client Records

A. Client records shall be maintained in the TGH and shall be kept secure and confidential. The provider shall have a written record for each client which shall include:

1. identifying data including:

a. name;

b. date of birth;

c. address;

d. telephone number;

e. social security number; and

f. legal status;

2. the client's pretreatment assessment, the referral and documentation pertaining to admission from Medicaid or its designee, initial diagnostic interview, nursing assessment and comprehensive treatment plan plus any modifications or updates;

3. the client's history including, where applicable:

a. family data;

b. next of kin;

c. educational background;

d. employment record;

e. prior medical history; and

f. prior service history;

4. written authorization signed by the client or, in the case of a minor, the legally responsible person for emergency care;

5. written authorization signed by the client or, in the case of a minor, the legally responsible person for maintaining the client's money, if applicable;

6. a current balance sheet, containing all financial transactions and required signatures, involving the personal funds of the client deposited with the provider;

7. required assessment(s) and additional assessments that the provider may have received or is privy to;

8. the names, addresses, and telephone numbers of the client's physician(s).

9. legible written progress notes or equivalent documentation and reports of the services delivered for each client for each visit. The written progress notes shall include, at a minimum:

a. the date and time of the visit and services;

b. the services delivered;

c. who delivered or performed the services;

d. observed changes in the physical or mental condition(s) of the client if applicable; and

e. doctor appointments scheduled or attended that day;

10. health and medical records of the client, including:

a. a medical history, including allergies; and

b. a description of any medical treatment or medication necessary for the treatment of any medical condition;

11. a copy of any advance directive that may have been executed by the client;

12. reports of any incidents of abuse, neglect, accidents or critical incidents, including use of passive physical restraints; and

13. reports of any client's grievances and the conclusions or dispositions of these reports. If the client's grievance was in writing, a copy of the written grievance shall be included.

B. TGHs shall maintain client records for a period of 10 years from discharge.

La. Admin. Code tit. 48, § I-6251

Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 38:416 (February 2012).

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and R.S. 40:2009.