Current through September 24, 2024
A. The medical record must be in compliance
with Miss. Admin. Code Part 200, Rule
1.3 and include the following
documentation:
1. Consent for treatment
obtained yearly,
2. Date of
service,
3. Type of service
provided,
4. Time session began and
time session ended,
5. Length of
time spent delivering the service,
6. Identification of individual(s) receiving
or participating in the service,
7.
Summary of what transpired in the session,
8. Treatment Plan reviewed and revised as
needed every six (6) months or as medically indicated,
9. Evidence that the session relates to the
goals and objectives established in the treatment plan,
10. Name, title, and signature of the
servicing provider providing the service,
11. Name, title, and signature of the
individual who documented the services, and
12. All documentation must be legible, easily
read and clearly understood.
B. A treatment plan must include, at a
minimum:
1. A dimensional approach non-axial
diagnosis with separate notations for important psychosocial, contextual
factors, and disability,
2.
Identification of the beneficiary's and/or family's strengths,
3. Identification of the clinical problems,
or areas of need,
4. Treatment
goals for each identified problem,
5. Treatment objectives that represent
incremental progress towards goals with target dates for achievement,
6. Specific treatment modalities and/or
strategies employed to meet each objective,
7. Date of implementation of the treatment
plan and signatures of the provider, beneficiary, and
parent/guardian.
8. Signatures from
the provider and beneficiary to verify the date of review and/or revision to
treatment plan, and
9. Signatures
obtained from each of the appropriate practitioners acknowledging the service
that each will provide for the beneficiary.
C. Documentation of services that are subject
to certification by the Department of Mental Health (DMH) must comply with the
Department of Mental Health's Record Guide and any supplemental instructions
provided by DMH in effect at the time the service is provided.
D. Providers must document, in writing with
the legal guardian's signature, that beneficiaries were given a free choice,
which must include freedom of choice for:
1.
The type of services,
2. The
provider of services, and
3. The
team members included in service planning.
42 C.F.R. §§
440.130,
441.57; Miss. Code Ann.
§§
43-13-117,
43-13-121; SPA
20-0022.
