15 Miss. Code. R. 16-1-41.51.8

Current through October 31, 2024
Rule 15-16-1-41.51.8 - Content

The medical record shall contain sufficient information to justify the diagnosis and warrant the treatment and end results. The medical record shall contain the following information: Identification date, chief complaint, present illness, physician's orders, past history, family history, physical examination, provisional diagnosis, clinical laboratory reports, x-ray reports, consultations, treatment medical and surgical, tissue report, progress notes, final diagnosis, discharge summary, autopsy findings.

15 Miss. Code. R. 16-1-41.51.8

Miss. Code Ann. § 41-9-17