Louisiana Administrative Code
Title 48 - PUBLIC HEALTH-GENERAL
Part I - General Administration
Subpart 3 - Licensing and Certification
Chapter 84 - End Stage Renal Disease Treatment Facilities
Subchapter D - Patient Care
Section I-8461 - Patient Records

Universal Citation: LA Admin Code I-8461

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

A. The facility is required to maintain a clinical record according to current professional standards for each patient.

1. This record shall:
a. contain all pertinent past and current medical, psychological, social and other therapeutic information, including the treatment plan;

b. be protected from unauthorized persons, loss, and destruction; and

c. be a central location for all pertinent patient information and be easily accessible to staff providing care.

2. Patient records can be copied and/or transferred from one facility to another provided that the patient signs the authorization for transfer of the records and provided that confidentiality of information is strictly enforced.

3. Patient records shall be maintained at the facility where the patient is currently active and for six months after discharge. Records may then be transferred to a centralized location for maintenance in accordance with standard practice and state and federal laws.

4. Confidentiality. Records shall:
a. be inaccessible to anyone not trained in confidentiality, unless they are granted access by legal authority such as surveyors, investigators, etc.; and

b. not be shared with any other entity unless approved in writing by the patient, except in medical emergencies.

5. Record Keeping Responsibility. A person who meets or exceeds the federal requirements, shall be designated as responsible for the patient records.

6. Contents. Patient records shall accurately document all treatment provided and the patient's response in accordance with professional standards of practice. The minimum requirements are as follows:
a. admission and referral information, including the plan/prescription for treatment;

b. patient information/data - name, race, sex, birth date, address, telephone number, social security number, school/employer, and next of kin/emergency contact;

c. medical limitations, such as major illnesses and allergies;

d. physician's orders;

e. psycho-social history/evaluation; and

f. treatment plan. The plan is a written list of the patient's problems and needs based on admission information and updated as indicated by progress or lack of progress. Additionally, the plan shall:
i. contain long and short term goals;

ii. be reviewed and revised as required, or more frequently as indicated by patient needs;

iii. contain patient-specific, measurable goals that are clearly stated in behavioral terms;

iv. contain realistic and specific expected achievement dates;

v. indicate how the facility will provide strategies/activities to help the patient achieve the goals;

vi. be followed consistently by all staff members; and

vii. contain complete, pertinent information related to the mental, physical, and social needs of the patient.

g. diagnostic laboratory and other pertinent information, when indicated;

h. progress notes by all disciplines; and

i. other pertinent information related to the individual patient as appropriate.

7. Computer data storage of pertinent medical information must:
a. meet the above criteria;

b. be easily retrievable and accessible when the patient is receiving dialysis; and

c. be utilized by care givers during dialysis treatment.

AUTHORITY NOTE: Promulgated in accordance with R.S. 46:153 and R.S. 40:2117.4.

Disclaimer: These regulations may not be the most recent version. Louisiana may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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