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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

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 amount of documentation that is necessary and provide a sample of a format with all information needed to satisfy the DMH record keeping requirements.

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