La. Admin. Code tit. 48 § I-5551

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

Section I-5551 - Records

A. Records shall be written and maintained in order to:

1. serve as a basis for planning for the individual in care;

2. provide a means of communication among all appropriate staff who are involved in the treatment;

3. justify and substantiate the adequacy of the evaluation and to form the basis for the ongoing development of the treatment plan;

4. facilitate continuity of treatment and enable the staff to determine, at a future date, what the individual's condition was at a specific time and what procedures were used;

5. furnish documentary evidence of ordered and supervised treatments, observations of the person's behavior, and responses to treatment;

6. serve as a basis for review, study, and evaluation of the treatment rendered;

7. protect the legal rights of the person, the facility, and staff;

8. provide data, when appropriate, for use in research and education.

B. Where parents or other family members are involved in the treatment program, appropriate documentation shall exist for them although there may not have to be a separate record for each family member involved.

C. While form and detail of the record may vary, all records shall contain all pertinent information and each person's record shall contain at least:

1. identification data and consent forms; when these are unobtainable, reasons shall be noted;

2. source of referral;

3. reason for referral, e.g., chief complaint, presenting problem;

4. record of the complete evaluation;

5. initial formulation and diagnosis based upon the evaluation;

6. written treatment plan. The treatment plan should include:

a. a diagnostic statement including psychiatric diagnosis as well as pertinent social and medical diagnostic information;

b. a statement of identified problems;

c. long and short-term treatment goes related to the problems;

d. treatment modalities to be utilized;

e. identification of persons assigned to carry out treatment;

f. signatures of the physician authorizing the treatment plan:

i. the treatment plan shall be modified as frequently as patient assessment indicates the need for change. It shall be reviewed at least every three months. The treatment plan shall reflect appropriate multi-disciplinary input by the staff, and shall reflect evidence of participation in the planning and approval of the plan by a qualified psychiatrist. Procedures that place the patient at physical risk or cause pain shall require special justification. Rationale for their use shall be specified in the treatment plan and shall be specifically reviewed and approved by a qualified psychiatrist;

7. history and record of all medications prescribed;

8. record of all medications administered by facility staff, including type of medication, dosages, frequency of administration, and person who administered each dose;

9. specific signed physician's authorization for any treatment which may place the individual at physical risk or cause pain (including physical restraint or seclusion) and detailed record of the cause of such treatment;

10. immunization record, record of adverse reactions and sensitivities to specific drugs;

11. documentation of course of treatment and all evaluations and examinations through progress notes;

12. a monthly summary of the person's response to his program prepared by qualified professionals involved in the treatment, including an analysis of the successes and failures of the plan and a recommendation for any modifications deemed necessary;

13. a summary of family visits and contacts as well as attendance and leaves from the facility and all consultations with the family;

14. all other appropriate information obtained from outside sources pertaining to the patient and reports of all extraordinary incidents or accidents;

15. discharge summary; and

16. plan for follow-up and documentation of its implementation.

D. Identification data and consent forms shall include the individual's name, address, home telephone number, date of birth, sex, Social Security number, race, height, color of hair and eyes, identifying marks, next of kin, school and grade or employment information, date initial contact and/or admission to the facility, legal status and legal documents, and other identifying data as indicated.

E. Identifying data on person's family shall include parents' names, their birthdate, their marital status, educational background, religious affiliations, and employment records. Additionally, the names, birthdates, educational and employment records of siblings shall be included where possible.

F. If the child or adolescent is in legal custody of individuals other than his parents, information on his guardian shall be included identical to that on the parent.

G. A recent photograph of the patient shall be included in the record.

H. Other information which shall be included in the individual's record is as follows:

1. the individual's medical history, both physical and mental, including any prior evaluations, examinations, and institutionalizations;

2. the sources of the individual's support, including Social Security, veteran's benefits, other forms of governmental assistance or insurance;

3. written authorization for field trips, photos, emergency medical assistance, inclusion in research projects, etc.;

4. the individual's grievances, if any;

5. an inventory of the individual's life skills.

I. Progress notes shall include regular notations by staff members, consultation reports and signed entries by authorized, identified staff. Notes and entries should contain all pertinent and meaningful observations and information. Progress notes by the clinical staff shall:

1. document a chronological picture of the patient's clinical course;

2. document all treatment rendered to the patient;

3. document the implementation of the treatment plan;

4. describe each change of the individual's conditions, responses of the person and his family to any significant events.

J. The discharge summary shall reflect the general observations and understanding of the individual's condition initially, during treatment, and at the time of discharge, and shall include a final appraisal of his fundamental needs. All relevant discharge diagnosis shall be recorded and coded in the standard nomenclature of the current Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association.

K. Entries in the person's records shall be made by all staff having pertinent information regarding the individual. Authors shall clearly sign and date each entry. Signature shall include position title. When mental health trainees are involved in the person's care, documented evidence shall be in the clinical record to substantiate the active participation of supervisory clinical staff. Symbols and abbreviations shall be used only when they have been approved by the clinical staff and when there is an explanatory legend. Final diagnosis- psychiatric, physical, and social- shall be recorded in full, and without the use of either symbols or abbreviations.

L. A facility shall have written policies and procedures regarding records which shall provide that:

1. all records shall be confidential, current, and accurate;

2. all records are the property of the facility and are maintained for the benefit of the person in care, the staff, and the facility;

3. the facility is responsible for safeguarding the information in the record against loss, defacement, tampering, or use by unauthorized persons;

4. the facility shall protect the confidentiality of information and communications among staff members and those in care;

5. except as required by law, the written consent of the individual, family or other legally responsible parties is required for the release of information;

6. records may be removed from the facility only according to the policies of the facility or as required by law and with authorization for release, appropriate records should be made available to any facility which the person subsequently attends as well as to his parents or legal guardians and to state agencies having responsibility for the care of the person.

M. There shall be evidence that all staff have received training, as part of new staff orientation and with periodic update, regarding the effective maintenance of confidentiality. This refers to discussions regarding patients inside and outside the facility as well as to records. Verbal confidentiality shall be discussed as part of employee training.

N. Appropriate records shall be directly and readily accessible to the staff caring for the person. The facility shall maintain a system of identification and filing to facilitate the prompt location of records.

O. There shall be written policies regarding the permanent storage, disposal/and/or destruction of records.

P. Records shall be retained for a period consistent with the prescriptive period of the state of Louisiana and consistent with the statute of limitations, of the Department of Health, Education, and Welfare regulations.

The following standards must be met in addition to the general standards by all facilities caring primarily for learning disabled persons.

La. Admin. Code tit. 48, § I-5551

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. 46:1971 through 1980.