15 Miss. Code. R. 16-1-49.25.1 - Medical Records Management

1. A medical record shall be maintained in accordance with accepted professional standards and practices on all clients admitted to the ICF-IID. 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. In an ICF IID Residenial Community Home, medical record services can be provided through a contractual service.

3. The ICF-IID 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 client's needs by all disciplines involved in the care of the client; 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 clients stay shall be centralized in the client's medical records.

7. Medical records of discharged clients shall be completed within thirty (30) 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 client reaches the age of twenty-one (21), plus an additional three (3) years.

Notes

15 Miss. Code. R. 16-1-49.25.1

Miss. Code Ann. § 43-11-13