La. Admin. Code tit. 48 § I-4719

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

Section I-4719 - Client's Case Record

A. A provider shall have written record for each client including the following information:

1. basic demographic data;

2. client's history including, where applicable, family data, medical history, educational background, employment history, etc.;

3. statement of presenting problem as seen by the client;

4. client's current situation;

5. assessment and service plan (including client's goals and objectives);

6. the findings made in periodic review of the service plan and recording of the client's progress as measured by objective indicators;

7. a departure summary;

8. any follow-up contacts made.

La. Admin. Code tit. 48, § I-4719

Promulgated by the Department of Health and Human Resources, Office of the Secretary, Division of Licensing and Certification, LR 13:246 (April 1987).

AUTHORITY NOTE: Promulgated in accordance with R.S. 46:2125.