La. Admin. Code tit. 48 § I-8079

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

Section I-8079 - Clinical Records

A. In accordance with accepted principles of practice the CRCC shall establish and maintain a clinical record for every individual receiving care and services. The record shall be complete, promptly and accurately documented, readily accessible and systematically organized to facilitate retrieval. The clinical record shall contain all pertinent past and current medical, nursing, social, and other therapeutic information, including the current POC under which services are being delivered.

B. CRCC records shall be maintained in a distinct location and not mingled with records of other types of health care related agencies.

C. Original clinical records shall be kept in a safe and confidential area which provides convenient access to clinicians.

D. The agency shall have policies addressing who is permitted access to the clinical records. No unauthorized person shall be permitted access to the clinical records.

E. All clinical records shall be safeguarded against loss, destruction and unauthorized use.

F. Records for individuals under the age of majority shall be kept in accordance with current state and federal law.

G. When applicable, the agency shall obtain a signed Release of Information Form from the patient and/or the patient's family. A copy shall be retained in the record.

H. The clinical records shall contain a comprehensive compilation of information including, but not limited to:

1. initial and subsequent plans of care and initial assessment;

2. documentation of a life-limiting diagnosis;

3. written physician's orders for admission and changes to the POC;

4. current clinical notes {at least the past 60 days);

5. plan of care;

6. signed consent and authorization forms;

7. pertinent medical history; and

8. identifying data, including:

a. name;

b. address;

c. date of birth;

d. sex;

e. agency case number; and

f. next of kin.

I. Entries are made for all services provided and are signed by the staff providing the service.

J. Complete documentation of all services and events (including evaluations, treatments, progress notes, etc.) are recorded whether furnished directly by staff or by arrangement.

La. Admin. Code tit. 48, § I-8079

Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 31:458 (February 2005).

AUTHORITY NOTE: Promulgated in accordance with R.S. 40:2175.14(B).