LAC 48:I.5347. Client Records

A. The CRC shall ensure: 1. a single client record is maintained for each client according to current professional standards; 2. policies and procedures regarding confidentiality of records, maintenance, safeguarding and storage of records are developed, implemented and followed; 3. safeguards are in place to prevent unauthorized access, loss, and destruction of client records; 4. when electronic health records are used, the most up to date technologies and practices are used to prevent unauthorized access; 5. records are kept confidential according to federal and state laws and regulations; 6. records are maintained at the center where the client is currently active and for six months after discharge; 7. six months post-discharge, records may be transferred to a centralized location for maintenance; 8. client records are directly and readily accessible to the clinical staff caring for the client; 9. a system of identification and filing is maintained to facilitate the prompt location of the client's record; 10. all record entries are dated, legible and authenticated by the staff person providing the treatment, as appropriate to the media; 11. records are disposed of in a manner that protects client confidentiality; 12. a procedure for modifying a client record in accordance with accepted standards of practice is developed, implemented and followed; 13. an employee is designated as responsible for the client records; 14. disclosures are made in accordance with applicable state and federal laws and regulations; and 15. client records are maintained at least 6 years from discharge. B. Record Contents. The center shall ensure that client records, at a minimum, contain the following: 1. the treatment provided to the client; 2. the client's response to the treatment; 3. other information, including: a. all screenings and assessments; b. provisional diagnoses; c. referral information; d. client information/data such as name, race, sex, birth date, address, telephone number, social security number, school/employer, and next of kin/emergency contact; e. documentation of incidents that occurred; f. attendance/participation in services/activities; g. treatment plan that includes the initial treatment plan plus any updates or revisions; h. lab work (diagnostic laboratory and other pertinent information, when indicated); i. documentation of the services received prior to admission to the CRC as available; j. consent forms; k. physicians' orders; l. records of all medicines administered, including medication types, dosages, frequency of administration, the individual who administered each dose and response to medication given on an as needed basis; m. discharge summary; n. other pertinent information related to client as appropriate; and 4. legible progress notes that are documented in accordance with professional standards of practice and: a. document implementation of the treatment plan and results; b. document the client's level of participation; and c. are completed upon delivery of services by the direct care staff to document progress toward stated treatment plan goals.