1. A medical record shall be maintained in accordance with accepted professional standards and practices on all residents admitted to the facility. The medical records shall be completely and accurately documented, readily accessible, and systematically organized to facilitate retrieving and compiling information.2. A sufficient number of personnel, competent to carry out the functions of the medical record service, shall be employed.3. The facility shall safeguard medical record information against loss, destruction, or unauthorized use.4. All medical records shall maintain the following information: identification data and consent form; assessments of the resident's needs by all disciplines involved in the care of the resident; medical history and admission physical exam; annual physical exams; physician or nurse practitioner/physician assistant orders; observation, report of treatment, clinical findings and progress notes; and discharge summary, including the final diagnosis.5. All entries in the medical record shall be signed and dated by the person making the entry. Authentication may include signatures, written initials, or computer entry. A list of computer codes and written signatures must be readily available and maintained under adequate safeguards.6. All clinical information pertaining to the residents stay shall be centralized in the resident's medical records.7. Medical records of discharged residents shall be completed within sixty (60) days following discharge.8. Medical records are to be retained for five (5) years from the date of discharge or, in the case of a minor, until the resident reaches the age of twenty-one (21), plus an additional three (3) years.9. A resident index, including the resident's full name and birth date, shall be maintained.15 Miss. Code. R. 16-1-45.25.1
Miss. Code Ann. § 43-11-13