Current through Register Vol. 50, No. 9, September 20, 2024
A. A
center shall have an organized record system which includes a written case
record for each participant. The case record shall contain administrative and
treatment data from the time of admission until the time that the participant
leaves the center.
B. The
participant's case record shall include:
1.
identifying information such as:
a.
name;
b. birth date;
c. home address;
d. Social Security number;
e. marital status;
f. gender;
g. ethnic group; and
h. religion;
2. identifying information for the
participant's personal representative, if applicable, such as:
a. name;
b. address; and
c. telephone number;
3. social and medical history including:
a. a complete record of admitting diagnoses
and any treatments that the participant is receiving;
b. history of serious illness, serious injury
or major surgery;
c. allergies to
medication;
d. a list of all
prescribed medications and non-prescribed drugs currently used;
e. current use of alcohol; and
f. the name of the participant's personal
physician and an alternate;
4. complete health records, when available,
including physical, dental and/or vision examinations;
5. a copy of the participant's individual
service plan including:
a. any subsequent
modifications; and
b. an
appropriate summary to guide and assist direct care staff in implementing the
participant's program;
6. the findings made in periodic reviews of
the plan including:
a. a summary of the
successes and failures of the participant's program; and
b. recommendations for any modifications
deemed necessary;
7. any
grievances or complaints filed by the participant and the resolution or
disposition of these grievances or complaints;
8. a log of the participant's attendance and
absence;
9. a physician's signed
and dated orders for medication, treatment, diet, and/or restorative and
special medical procedures required for the safety and well-being of the
participant;
10. progress notes
that:
a. document the delivery of all
services identified in the individualized service plan;
b. document that each staff member is
carrying out the approaches identified in the individualized service plan that
he/she is responsible for;
c.
record the progress being made and discuss whether or not the approaches in the
individualized service plan are working;
d. record any changes in the participant's
medical condition, behavior or home situation which may indicate a need for a
change in the individualized service plan; and
e. document the completion of incident
reports, when appropriate; and
NOTE: Each individual responsible for providing direct
services shall record progress notes at least weekly, but any changes to the
participant's condition or normal routine should be documented on the day of
the occurrence.
11. discharge planning and referral.
11.a. - 12. Repealed.
C. All entries made by center
staff in participants' records shall be legible, signed and dated.
D. The medications and treatments
administered to participants at the center shall be charted by the appropriate
staff.
E. The center may produce,
maintain and/or store participant case records either electronically or in
paper form.
F. The center shall
ensure that participant case records are available to staff who are directly
involved with participant care.
AUTHORITY NOTE:
Promulgated in accordance with R.S. 36:254 and 40:2120.41-46.
