Rule 15-16-1-46.48.1 - Clinical Record ContentA clinical record shall be established and maintained for every person admitted to home health services. The original or signed copy of clinical reports shall be filed in the clinical record. Clinical records shall contain:
1. Appropriate identifying information for the patient, household members and caretakers, pertinent diagnoses, medical history, and current findings;3. Initial and periodic patient assessments by the professional discipline responsible performed in the home;5. Clinical notes signed and dated by all disciplines rendering service to the patient for each contact, written the day of service and incorporated into the patient's clinical record at least weekly;6. Reports of case conferences including staff contacts with physicians, podiatrists, nurse practitioners, physician assistants, or clinical nurse specialists, and other members of the health care pertaining to the patients. Case conferences shall be conducted and documented at least every sixty (60) days or more often as required by the patient's condition;7. Progress notes written at least every sixty (60) days or more frequently as warranted by the patient's conditions;8. Documentation of supervisory visits by a registered nurse or other applicable supervisory personnel;10. A copy of the patient transfer information sheet if patient is admitted to another health care facility;11. Home health aide written instructions;12. Verbal orders shall be taken only by registered nurses or health care professionals, and immediately recorded in the patient's clinical record with the date. These orders shall be countersigned by the physician, podiatrist, nurse practitioner, physician assistant, or clinical nurse specialist; and13. Duplicate copies of all laboratory results as reported by the referral laboratory.15 Miss. Code. R. § 16-1-46.48.1
Miss. Code Ann. § 41-71-13