LAC 48:I.4719. Client's Case Record

A. A provider shall have written record for each client including the following information: 1. basic demographic data; 2. client's history including, where applicable, family data, medical history, educational background, employment history, etc.; 3. statement of presenting problem as seen by the client; 4. client's current situation; 5. assessment and service plan (including client's goals and objectives); 6. the findings made in periodic review of the service plan and recording of the client's progress as measured by objective indicators; 7. a departure summary; 8. any follow-up contacts made.