LAC 48:I.5637. Client Records

A. The BHS provider shall ensure that: 1. a client record is maintained for each client according to current professional standards; 2. policies and procedures regarding confidentiality, maintenance, safeguarding and storage of records are developed and implemented; 3. records are stored in a place or area where safeguards are in place to prevent unauthorized access, loss, and destruction of client records; 4. when electronic health records are used, the most current technologies and practices are used to prevent unauthorized access; 5. records are kept confidential according to federal and state law and regulations; 6. records are maintained at the provider 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 direct care staff caring for the client; 9. a system of identification and filing is maintained to facilitate the prompt location of the client’s records; 10. all record entries are dated, legible and authenticated by the staff person providing the service or treatment, as appropriate to the media used; 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; 15. client records are maintained at least 6 years from discharge, and for minors, client records are maintained at least 10 years. B. Contents. The provider shall ensure that a client record, at a minimum, contains the following: 1. the treatment provided to the client; 2. the client’s response to the treatment; 3. all pertinent medical, psychological, social and other therapeutic information, including: a. initial assessment; b. admission diagnosis; c. referral information; d. client information/data such as name, race, sex, birth date, address, telephone number, social security number, school/employer, and authorized representative, if applicable; e. screenings; f. medical limitations such as major illnesses, allergies; g. treatment plan that includes the initial treatment plan plus any updates or revisions; h. lab work including diagnostic, laboratory and other pertinent information, when indicated; i. legible written progress notes or equivalent documentation; j. documentation of the services delivered for each client signed by the client or responsible person for services provided in the home or community; k. documentation related to incidents; l. consent forms; m. physicians’, advanced practice registered nurses (APRNs’), physician assistants’, or LMHPs’ orders; n. a record of all medicines administered by the BHS provider or self-administered by the client, including medication name and type, dosage, frequency of administration, route and person who administered each dose; o. discharge summary; p. documents, records, photos, testimonials, and other significant health-related collateral information provided by a client’s family member, caregiver, friend, or healthcare professional, except in the event the healthcare professional or healthcare provider believes that acceptance and inclusion of the information in the medical record is not relevant to the client’s care or treatment; and q. other pertinent information related to client as appropriate. 4. progress notes that are documented in accordance with professional standards of practice and that: 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.