Current through Register Vol. 50, No. 9, September 20, 2024
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.
AUTHORITY NOTE:
Promulgated in accordance with
R.S.
46:1971 through
1980.
