Transcription of Final PDF 2016 Record Guide for Distribution
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Final PDF 2016 Record Guide for Distribution
Department of Mental Health Record Guide For Mental Health, Intellectual and Developmental Disabilities, and Substance Use Disorders Community Providers 2016 Revision Mississippi Department of Mental Health Diana S. Mikula, Executive Director 239 North Lamar Suite 1101 Jackson, MS 39201 DMH Record Guide Contents i TABLE OF CONTENTS Section A General Information Page 1 Section B All Records Page 5 Face Sheet Consent to Receive Services Rights of Individuals Receiving Services Acknowledgment of Grievance Procedures Consent to Release/Obtain Information Medication/Emergency Contact Information Section C Required for All Mental Health and Substance Use Page 21 Records Initial Assessment Trauma History Individual Service Plan Individual Crisis Support Plan Recovery Support Plan Progress Note Weekly Progress Note Periodic Staffing/Review of the Individual Service Plan Readmission Assessment Update Substance Use Disorder Specific Assessment Section D As Needed for All Records Page 57 Initial Assessment and Crisis Contact Summary Serious Incident Report Medical Examination Documentation of Healthcare Provider Visit Self-Administration Medication
The emphasis of this Record Guide is on guidance needed to satisfy any and all ... Because of the DMH mandatory data collection and reporting requirements, along with the increasing use of electronic record keeping that many providers are implementing, the need to maintain paper forms is declining. This guide seeks to describe the type and ...
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