23 Miss. Code. R. 221-1.6 - Documentation/Record Maintenance

A. Providers of family planning and family planning related services must comply with the requirements for maintenance of records outlined in Miss. Admin. Code Part 200, Rule 1.3.

B. Documentation of family planning and family planning related services must include, but are not limited to:

1. Signed and dated consent for treatment, if applicable,

2. Signed and dated consent for sterilization, if applicable, as outlined in Miss. Admin. Code Part 202, Rule 5.3.,

3. Date of service and reason for visit,

4. Demographic information, including name, address, Medicaid number, date of birth, sex, and marital status,

5. Comprehensive health history, updated at least annually, including, but not limited to:

a) Health risk factors,

b) Personal medical, sexual and contraceptive history,

c) Plans for having children, and

d) Obstetrical and gynecological history.

6. Complete family history, updated at least annually,

7. Allergies, including type, reaction, and treatment,

8. Specific name/type of all diagnostic studies, including, but not limited to, laboratory and the result/finding of the studies,

9. Treatments/procedures rendered,

10. Physical findings including vital signs and weight,

11. Documentation of all medications including contraceptives whether administered by the provider, prescribed, or issued via physician/prescriber samples, and must include, but not limited to:

a) The name,

b) Strength,

c) Dose,

d) Route of administration,

e) Site for all injectables, and

f) Manner in which prescription was issued including, but not limited to, in writing, by telephone, electronically or via facsimile.

12. Contraceptive supplies whether administered by the provider, prescribed, or issued via provider/prescriber samples,

13. Contraceptive devices,

14. Contraception counseling,

15. Date, time, and signature for all entries in the beneficiary's record, and

16. Provider's order, which must include the time, date, and signature, for all medications, treatments, and procedures rendered.

Notes

23 Miss. Code. R. 221-1.6

42 CFR Part 441, Subpart F; Miss. Code Ann. §§ 43-13-117, 43-13-118, 43-13-121, 43-13-129.

Amended 7/1/2015