32 Miss. Code. R. 21-2-2.2
During early contact with the client, the case recording should emphasize history, present adjustment and environmental situations, and the objective measures of, or reports on, his/her physical and mental capacities.
Good documentation provides continuity with respect to all general information, evaluations, and services provided. The recorded information about a client should be accurate and reliable. If there are any contradictory reports, they are to be fully explained or reconciled in the case record. Reported observations or generalizations about a client should be recorded in such a way that the reliability of the reports can be determined. The source of all recorded data about the client should be clearly indicated.
The case record should indicate the nature and extent of professional contribution to the progress of the case. It should include any problems the counselor encountered in working with the client or helping secure services from other community agencies. The case documentation should reflect the effectiveness of the services. There should be enough information in the record to indicate whether or not treatment was successful, the client developed the vocational skills that were planned, and the personal counseling and social adjustments resulted in an improvement in the client's situation. All case records are subject to legal subpoena and may be used as evidence in fair hearings or court proceedings. Therefore, opinion-based (non-factual) observations should not be entered into the record.
32 Miss. Code. R. 21-2-2.2