15 Miss. Code. R. 16-1-52.9.18

Current through December 10, 2024

Rule 15-16-1-52.9.18 - Contents of Records

The medical record shall contain sufficient information to justify the diagnosis and warrant the treatment and end results. The patient record shall describe the patient's health status at the time of admission, the services provided and the patient's progress in the facility, and the patient's health status at the time of discharge. The patient record shall provide information for the review and evaluation of the treatment provided to the patient. When appropriate, data in the patient record shall be used in training, research, evaluation, and quality assurance programs. When indicated, the patient record shall contain documentation that the rights of the patient and of the patient's family are protected. The patient record shall contain documentation of the patient's and, as appropriate, family members' involvement in the patient's treatment program. When appropriate, a separate record may need to be maintained on each family member involved in the patient's treatment program. The patient record shall contain identifying data that is recorded on standardized forms. This identifying data shall include the following:

1. full name;

2. home address;

3. home telephone number;

4. date of birth;

5. sex;

6. race or ethnic origin;

7. next of kin;

8. education;

9. marital status;

10. type and place of employment;

11. date of initial contact or admission to the facility;

12. legal status, including relevant legal documents;

13. other identifying data as indicated;

14. date the information was gathered; and

15. signature of the staff member gathering the information.

15 Miss. Code. R. 16-1-52.9.18

Miss. Code Ann. § 41-9-17