32 Miss. Code. R. 23-13.09 - Case Record Requirements

A case file should include the following:

1. Case identification data

2. Name and address of client's guardian, if appropriate

3. Pertinent history, diagnosis of disability, limitations, special needs (e.g., communication), and desired outcomes/expectations

4. Prescribed medications, the name of the prescribing physician and other relevant medical information

5. Reports of initial and ongoing assessments

6. Reports from referring sources

7. Reports from outside consultants

8. Designation of program manager

9. Evidence of the direct involvement of the person served in the decision making process related to his/her program.

10. Reports of staff conferences and, if held, family conferences

11. Client's individual PAT objectives for each instructional area

12. Progress reports from each service area (signed and dated)

13. Pertinent correspondence

14. Release forms

15. Exit interview

16. Follow-up reports

In addition to the above, for clients who receive Vocational Evaluation services, case records will include the following:

1. Potential employment goals

2. IVEP (Individualized Vocational Evaluation Plan)

3. Documentation of evaluation results that pertain to work tolerance (physical/mental tolerance, persistence in work/physical activity).

Notes

32 Miss. Code. R. 23-13.09