LAC 48:I.9891
LAC 48:I.9891. Content
Cite as La. Admin. Code tit. 48, pt. I, § 9891
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.