LAC 48:I.5731. Client Records

A. In addition to the general requirements for client records, each client record shall contain: 1. recording of medication administration and dispensing in accordance with federal and state requirements; 2. results of five most recent drug screen tests with action taken for positive results; 3. physical status and use of additional prescription medication; 4. monthly or more frequently, as indicated by needs of client, contact notes and progress notes which include employment/vocational needs, legal and social status, and overall individual stability; 5. documentation and confirmation of the factors to be considered in determining whether a take-home dose is appropriate; 6. documentation of approval of any exception to the dispensing restrictions of take-home doses and the OTP practitioner’s justification for such exception; and 7. any other pertinent information.