23 Miss. Code. R. 223-4.9

Current through December 10, 2024

Rule 23-223-4.9 - Documentation Requirements

A. Nurses providing private duty nursing (PDN) services must document all nursing care rendered during each shift including, but not limited to:

1. Current physician's orders,

2. Medications administered and response,

3. Treatments administered and response,

4. Any other professional nursing skills provided during the shift,

5. Narrative skilled nursing services notes including accurate dates and times of services and documentation that a copy was given to parent and/or legal guardian or caregiver, and

6. Any significant changes in the beneficiary's condition,

B. Weekly timesheets must be maintained for each nurse providing PDN services that include:

1. The date the services were provided,

2. Begin and end times of services and a list of services provided during that time,

3. The dated signature of the nurse, and

4. The dated signature of the beneficiary's guardian or legal representative.

C. The PDN provider must establish and maintain a permanent, legible medical record for each beneficiary at the provider's office which must include, at a minimum, the following:

1. Physician orders updated and signed by the physician every six (6) months,

2. Current physician's treatment plan updated every six (6) months,

3. Nursing plan of care (POC) based on the diagnosis(es), clinical and social status of the beneficiary including measurable goals updated every six (6) months,

4. Documentation of changes in clinical status and/or significant occurrences,

5. Weekly progress notes,

6. Monthly summaries must include the following, at a minimum:

a) Nursing skills provided,

b) Progress or lack of progress toward goals,

c) Clinical and social status of the beneficiary,

d) Current medications and treatments and changes made during the month, and

e) Changes in the POC.

7. Information regarding other home care services being provided to the beneficiary including:

a) The specific services provided,

b) Date and times of services, and

c) The providers of the services.

8. Copies of all prior authorizations.

D. All records must be maintained and retained in accordance with HIPPA and Medicaid regulations. [Refer to Part 200, Rule 1.3.]

E. The Division of Medicaid will not reimburse PDN providers for both PDN and PCS services provided at the same time to the same beneficiary.

23 Miss. Code. R. 223-4.9

Miss. Code Ann. §§ 43-13-117, 43-13-121.

Adopted 4/1/2020

Amended 6/1/2020

Amended 7/1/2020