OAR 410-133-0320
Documentation and Record keeping Requirements
(1)
Record keeping must conform and adhere to federal, state, and local laws and regulations.(2)
Records must record history taken, procedures performed, tests administered, results obtained, and conclusions and recommendations made. Documentation may be in the form of a “SOAP” (subjective objective assessment plan) note, or equivalent.(3)
Providers will retain information necessary to support claims submitted to the Authority including: documentation and supervision of the specific health services provided, the extent of the health service provided, the dates and the name and credentials of medically qualified staff who provided the service to the Medicaid-eligible student for seven years from date of payment. This documentation must meet the requirements of and must be made available pursuant to the requirements in the General Rules, OAR 410-120-1360 (Requirements for Financial, Clinical and Other Records) Requirements for Financial, Clinical and Other Records. These requirements may be met if the information is included in the IEP or IFSP and the school medical provider maintains adequate supporting documentation at the time the service is rendered, consistent with the requirements of OAR 410-120-1360 (Requirements for Financial, Clinical and Other Records):(a)
Supporting documentation should:(A)
Be accurate, complete, and legible;(B)
Be typed or recorded using ink;(C)
Be signed by the individual performing the service including their credentials or position;(D)
Be signed and initialed in accordance with licensing board requirements for each clinical entry by the individual performing the service;(E)
Be reviewed and authenticated by the supervising therapist in compliance with their licensing board requirements (Also see covered services 410-133-0080 (Coverage) and not covered services 410-133-0200 (Not Covered Services).);(F)
Be for covered health services provided as specified for the service period indicated on the Medicaid-eligible student’s current IEP or IFSP.(b)
Corrections to entries must be recorded by:(A)
Striking out the entry with a single line that does not obliterate the original entry or amend the electronic record preserving the original entry; and(B)
Dating and initialing the correction.(c)
Late entries or additions to entries shall be documented when the omission is discovered with the following written at the beginning of the entry: “late entry for (date)” or “addendum for (date).”(4)
Supporting documentation for Medicaid reimbursed health services described in a Medicaid-eligible student’s IEP or IFSP must be kept for a period of seven years as part of the student’s education record, which may be filed and kept separately by school health professionals and must include:(a)
A copy of the Medicaid-eligible student’s IEP or IFSP as well as any addendum to the plan that correlates with the covered health services provided and reimbursed by Medicaid;(b)
A notation of the diagnosis or condition being treated or evaluated, using specific medical or mental health diagnostic codes;(c)
Results of analysis of any mental health or medical analysis, testing, evaluations, or assessments for which reimbursement is requested;(d)
Documentation of the location, duration, and extent of each health service provided, by the date of service, signed and initialed by medically qualified staff in accordance with their licensing board requirements (electronic records can be printed);(e)
The record of who performed the service and their credentials or position;(f)
The medical recommendation to support the service;(g)
Periodic evaluation of therapeutic value and progress of the Medicaid-eligible student to whom a health service is being provided;(h)
Record of medical need for necessary and appropriate transportation to a covered health service is supported by a transportation vehicle trip log including specific date transported, client name, ID number, and point of origin and destination consistent with transportation services specified in the child’s IEP or IFSP as part of record-keeping requirements; and(i)
Attendance records for Medicaid-eligible students to support dates for covered services billed to Medicaid;(j)
In supervisory situations, the record documenting therapy provided must name both the assistant providing services and the supervising therapist including credentials. The licensed health care practitioner who supervises and monitors the assessment, care, or treatment rendered by licensed or certified therapy assistants shall meet the minimum standards required by their licensing board and shall co-sign for those services where appropriate with their name and professional titles (documentation may not be delegated except in emergency situations).
Source:
Rule 410-133-0320 — Documentation and Record keeping Requirements, https://secure.sos.state.or.us/oard/view.action?ruleNumber=410-133-0320.