23 Miss. Code. R. 221-2.9 - Documentation/Record Maintenance

A. Providers of Family Planning Waiver (FPW) services must comply with the requirements for maintenance of records outlined in Miss. Admin. Code Part 200, Rule 1.3.

B. FPW services documentation must include, but is not limited to:

1. Date of service,

2. Reason for visit,

3. Physical findings including vital signs, and weight,

4. Documentation of a physical exam, clinical breast exam and cervical cancer screenings conducted at the initial and annual visits,

5. Treatments/procedures rendered,

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

7. Allergies including type, reaction and treatment,

8. 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.

9. Complete family history, updated at least annually,

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

11. Documentation of all medications including contraceptives, whether administered by the provider, prescribed, or issued via samples and must include the:

a) 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 samples,

13. Contraceptive devices,

14. Documentation of education and counseling on contraception management, sexually transmitted infections (STI)/sexually transmitted disease (STD), human immunodeficiency virus infection (HIV) and acquired immune deficiency syndrome (AIDS),

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

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

17. Signed and dated consent for treatment, as applicable,

18. Primary care referrals, if applicable,

19. OB/GYN referral if beneficiary is determined to be pregnant, and

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

Notes

23 Miss. Code. R. 221-2.9

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

Revised to correspond with the Family Planning Waiver renewal (eff. 01/01/2015); Amended 7/1/2015 Revised to correspond with the Family Planning Waiver renewal (eff. 01/01/2018) Amended 11/1/2018