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Client Records: Content, Security, Retention, and Access

Sets out what the Agency keeps in each client record under LAC 48:I.5057, what stays in the client’s home, how entries are made and corrected, where records are stored and protected, who may see or receive them, and how long they are kept: at least six years, and for LT-PCS six years from the date of the last payment period.

Preview: full text with a package
About this policy
Policy number
LA-HC-REC-01
Version
1.0
Main rule
LAC 48:I.5057
Library
Louisiana home care · 50 policies
Category
Records
Sections
22

In short

  • Every client has one complete record at the office; current progress notes stay in the client’s home folder.
  • Never take client records out of the office, and keep the home folder in the client’s home.
  • Write in ink, sign with your name, title and full date; fix mistakes with one line, "error" and your initials.
  • Never use correction fluid, never backdate, and never sign for someone else.
  • Send any request for records or copies to the privacy official the same day.

What's inside

22 sections. The full text comes with the One-time Policy Pack.

Full text with a package
  • Terms of Reference
  • 1. Purpose
  • 2. Scope
  • 3. Definitions
  • 4. Policy Statement (LAC 48:I.5057)
  • 5. What Each Client Record Holds
  • 6. Records Kept in the Client’s Home
  • 7. Entries, Signatures and Corrections
  • 8. Organization of the Record
  • 9. Where Records Are Kept and How They Are Protected
  • 10. Client Access to the Record
  • 11. Releasing Information to Others
  • 12. Access by LDH and Other Authorities
  • 13. How Long Records Are Kept
  • 14. Transfer, Discharge and Closure
  • 15. Responsibilities
  • 16. Records and Compliance Monitoring
  • 17. Staff Training
  • 18. References
  • 19. Related Policies and Forms
  • 20. Approval
  • 21. Revision History

An inspector may ask

  • Show me the record for this client: identifying data and legal status, service plan, history, service agreement, emergency care authorization, assessments, physician and dentist, progress notes, medical information and any advance directive.
  • What records do you keep in the client’s home? Show me the current progress notes there.

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