Rule 23-223-6.6 - DocumentationA. 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,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, and12. 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, and9. 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:2. The provider of services, and3. The team members included in service planning.23 Miss. Code. R. 223-6.6
42 C.F.R. §§ 440.130, 441.57; Miss. Code Ann. §§ 43-13-117, 43-13-121; SPA 20-0022.