A. A single record
must be maintained for each person receiving services (Exceptions: Substance
Use Prevention Services, Consultation and Education Services, and Family
Support and Education Services) from the agency provider. In lieu of access to
people's records, employees may utilize an on-site working record that contains
information from the person's record that is utilized to provide services at
that location (e.g., individual plans, emergency contact information, and
medication profile).
B. The agency
provider must maintain an indexing or referencing system that allows for
locating people's records whenever they are removed from the central file
area.
C. Records of people served
must be readily accessible to authorized personnel and there must be written
procedures assuring accessibility to people's records by emergency personnel
after hours.
D. When feasible,
information about people receiving services and care delivery should be
captured and stored electronically, in a manner which is privacy protected and
in accordance with applicable laws (e.g., HIPAA), rules and regulations, and
any issued DMH policies, procedures, and guidelines surrounding the use of
electronic health records.
All entries in people's paper records must be in a permanent
form (i.e., ink), accurate, legible, dated, signed, and include the credentials
of employees making the entry. Corrections in the original information entered
in the record(s) must be made by marking a single line through the changed
information. Changes must be initialed and dated by the person making the
change. Cover up, erasure, or marking out of original information is not
permissible.
E. Late entries
to the person's record should be avoided. However, late entries must also be
documented as soon as possible. The date and time when the entry is being made
must be included. Events described in the late entry must include the actual
date and time (if available) that the event(s) occurred.
F. No information in a person's record shall
contain the whole name or other identifiable information of another person
receiving services.
G. For the
purposes of DMH provider certification only: For substance use service
caseloads, the case may be placed in an inactive status on the
180th day of no recorded contact. The case must be
closed after one (1) year of no recorded contact. For mental health service
caseloads, the case may be placed in an inactive status when no contacts are
recorded for one (1) year. After two (2) years, following an attempt to contact
the person, the case must be closed. A separate rule exists in Chapter 2
regarding records maintenance as it relates to DMH compliance
activities/reports.
H. Record
Retention/Disposal of Records: Certified agency providers should follow the
current Healthcare Records Retention Guidelines as prescribed/published by the
Mississippi Department of Archives and History (MDAH). Providers should further
be in compliance with all federal and state laws for the storage of any
records. If a certified provider ceases its operation or is no longer certified
by DMH, the provider will be solely responsible for maintaining the records for
the appropriate amount of time as prescribed by MDAH. DMH is not responsible
for retaining records or the cost to store them.
