La. Admin. Code tit. 48, § I-4719 - Client's Case Record
A. A provider
shall have written record for each client including the following information:
1. basic demographic data;
2. client's history including, where
applicable, family data, medical history, educational background, employment
history, etc.;
3. statement of
presenting problem as seen by the client;
4. client's current situation;
5. assessment and service plan (including
client's goals and objectives);
6.
the findings made in periodic review of the service plan and recording of the
client's progress as measured by objective indicators;
7. a departure summary;
8. any follow-up contacts made.
Notes
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