Current through Register Vol. 50, No. 9, September 20, 2024
A. A complete
record shall be maintained for each individual that is adequate for:
1. planning and continuous evaluation of the
individual's habilitation and educational program;
2. furnishing documentary evidence of the
individual's progress and of his response to his habilitation program;
and
3. protecting the legal rights
of the individual facility, and staff.
B. All entries in the individual's record
shall be legible, dated, and authenticated by the signature and identification
of the person making the entry.
C.
Symbols and abbreviations are to be used in record entries only if a legend is
provided to explain them.
D. The
following information shall be entered in the individual's record at the time
of admission to the facility:
1.
identification data on the individual, including name, date, and place of
birth, date of admission, citizenship status, Social Security number, legal
status, sex, race, height, weight, color of hair, color of eyes, identifying
marks and a recent photograph;
2.
the individual's family history, including the parents' names, their birthdates
and birthplaces, their marital status, their educational backgrounds, religious
affiliations, and their employment records;
3. the individual's medical history, both
physical and mental, including any prior institutionalization;
4. the type and legal status of the
individual's admission to the facility and his legal competency
status;
5. the sources of the
individual's support, including Social Security, veteran's benefits, other
forms of governmental assistance or insurance;
6. reports on the pre-admission evaluation
and any other histories, evaluations, and examinations;
7. the immunization record. If immunization
records are not complete, a statement from a physician with reasons for
incomplete immunization;
8. written
authorizations for field trips, photos, emergency medical assistance, inclusion
in research projects, etc.
E. Other information which shall be included
in the individual's record is as follows:
1.
his grievance, if any;
2. any
inventory of his life skills;
3.
records of subsequent physical or mental examinations;
4. a copy of his plan and any modifications
thereto and an appropriate summary to guide the facility's staff in
implementing his program;
5. a
monthly summary of his response to this 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. A summary of the person's response to his program shall be forwarded
at least quarterly to the funding agency;
6. a copy of the plan for the individual
which will take effect when he leaves the facility and a summary of the steps
that have been taken to implement that program;
7. the history and present status with
respect to medication and a record of any seizures, illnesses, treatments
thereof, and immunizations;
8. a
signed order by the appropriate qualified professional for any physical
restraints and a record of all periods of justification and authorization for
each;
9. a summary of family visits
and contacts, as well as attendance and leaves, from the facility;
10. a description of any extraordinary
incident or accident in the facility involving the individual to be entered by
a staff member noting his personal knowledge of the incident or accident or
other source of information, including any reports of investigations of
mistreatment of the individual, as required elsewhere in these
standards.
11. periodic updating of
the information recorded at the time of admission.
F. At the time of discharge or transfer from
the facility, a discharge summary shall be prepared and shall be available to
the parents or the funding agency. With the permission of the parent, the
discharge summary shall also be forwarded to any facility which the student
attends subsequently.
G. The
records for each individual shall be readily available to the appropriate
qualified professionals and staff members who are directly involved with the
particular individual.
H. The
parent, tutor, or guardian of the child shall also be permitted access to these
records.
I. All information
contained in an individual's record shall be considered privileged and
confidential.
J. The record is the
property of the facility, whose responsibility it is to secure the record
against loss, defacement, tampering, or use by unauthorized persons.
K. There shall be written policies governing
access to duplication of and dissemination of information from the
record.
L. Written consent of the
individual, if competent and of the age of majority, or his guardian shall be
required for the release of information to persons not otherwise authorized to
receive it.
M. The individual's
words shall be maintained in an organized manner appropriate to the needs of
the facility and the individual served.
N. 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.
O. There shall be available sufficient
appropriately qualified staff and necessary supporting personnel to facilitate
the accurate processing checking, indexing, filing and prompt retrieval of
records and record data.
AUTHORITY NOTE:
Promulgated in accordance with
R.S.
46:1971 through
1980
