15 Miss. Code. R. 16-1-4.14.3

Current through September 18, 2024

Rule 15-16-1-4.14.3 - Client Records

. The facility shall maintain a separate record for each client. Such record shall be current and complete and shall be maintained in the facility or in a central administrative location readily available to facility staff and to the licensing agency. All records shall be maintained in an accessible, standardized order and format and shall be retained and disposed of in accordance with state laws.

1. Client records shall contain the following:

a. General information form, including at a minimum: Identifying information to include at least client's name, marital status, date of birth, and gender;

b. Dates of admission and discharge;

c. Client's written authorization and contact information of the representative or responsible person;

d. Admission agreement(s) and financial statements;

e. Clients' rights and licensed facility's rules, signed, dated, and witnessed;

f. Medical referral from physician or nurse practitioner/physician assistant;

g. The admission assessment documenting the appropriateness of the client's admission to facility;

h. Individual service plan, updates, and quarterly reviews;

i. Name and 24 hour contact information for the primary physician and any other physician involved in the client's care;

j. Initial and annual health and physicals;

k. Current medication record, including any reactions to such medication;

l. Progress notes of care and services received and response to treatment;

m. Social services and activity contacts;

n. Record of all personal property and funds;

o. Representative payee statement, if applicable; and

p. Physician orders or nurse practitioner/physician assistant orders (including, but not limited to, therapies, diets, medications, etc.) and medication administration records.

2. The records, as described in this section, shall be made available to the client, the client's family, or other responsible party for the client upon reasonable request.

3. The facility shall report and comply with the annual MSDH TB Program surveillance procedures.

15 Miss. Code. R. 16-1-4.14.3

Miss. Code Ann. § 41-75-13

Adopted 8/16/2017