Record Management

Record Management 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.