Louisiana Administrative Code
Title 48 - PUBLIC HEALTH-GENERAL
Part I - General Administration
Subpart 3 - Licensing and Certification
Chapter 98 - Nursing Facilities
Subchapter H - Resident Clinical Records and Financial Information
Section I-9891 - Content
Universal Citation: LA Admin Code I-9891
Current through Register Vol. 50, No. 9, September 20, 2024
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.
AUTHORITY NOTE: Promulgated in accordance with R.S. 40:2009.1-2116.
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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