La. Admin. Code tit. 48 § I-9891

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

Section I-9891 - Content

A. The clinical record shall contain sufficient information to identify the resident clearly, to justify the diagnosis and treatment, and to document the results accurately.

B. At a minimum, each clinical record shall contain:

1. sufficient information to identify the resident;

2. physician orders;

3. progress notes by all practitioners and professional personnel providing services to the resident;

4. a record of the resident's assessments;

5. the plan of care;

6. entries describing treatments and services provided; and

7. reports of all diagnostic tests and procedures.

La. Admin. Code tit. 48, § I-9891

Promulgated by the Department of Health, Bureau of Health Services Financing, LR 421925 11/1/2016).

AUTHORITY NOTE: Promulgated in accordance with R.S. 40:2009.1-2116.