OAR 410-172-0620
Documentation Standards

(1)

OHP providers shall maintain records that fully support the extent of services for which payment has been requested and provide the records to the Division upon request.

(2)

All records shall document the specific service provided, the number of services comprising the service provided, the extent of the service provided, the dates on which the service was provided, and the individual who provided the service.

(3)

Clinical records shall document the recipient’s diagnosis and the medical need for the service.

(4)

The record shall be annotated each time a service is provided and be signed or initialed by the individual providing the service.

(5)

Information contained in the record shall be appropriate in quality and quantity to meet the professional standards applicable to the provider and any additional standards for documentation found in these rules, other Division rules, and pertinent contracts.

(6)

For AMH certified providers, in addition to meeting the requirements in this rule, clinical documentation for behavioral health services shall also comply with the requirements in OAR 309-019-0135 (Entry and Assessment) through OAR 309-019-0140 (Service Plan and Service Notes), and clinical documentation standards for substance use disorder services shall comply with OAR 309-018-0140 (Assessment) through OAR 309-018-0150 (Service Record).

Source: Rule 410-172-0620 — Documentation Standards, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-172-0620.

410–172–0600
Acronyms and Definitions 410–172–0610
Provider Enrollment 410–172–0620
Documentation Standards 410–172–0630
Medically Appropriate 410–172–0640
Behavioral Health Services Fee Schedule 410–172–0650
Prior Authorization 410–172–0660
Rehabilitative Behavioral Health Services 410–172–0670
Substance Use Disorder Treatment Services 410–172–0680
Residential Treatment Services for Children 410–172–0690
Admission Procedure for Residential Treatment Services for Children 410–172–0695
Intensive In-Home Behavioral Health Treatment Services for Youth (IIHBT) 410–172–0705
Residential Rate Standardization 410–172–0710
Residential Personal Care 410–172–0720
Prior Authorization and Re-Authorization for Residential Treatment 410–172–0730
Payment Limitations for Behavioral Health Services 410–172–0745
Exception Criteria for Facial Gender Confirmation Surgery (FGCS) 410–172–0760
Applied Behavior Analysis 410–172–0770
Individual Eligibility for Applied Behavioral Analysis Treatment 410–172–0780
Behavioral Health Personal Care Attendant Program 410–172–0790
Eligibility for Behavioral Health Personal Care Attendant Services 410–172–0800
Personal Care Attendant Employer-Employee Relationship 410–172–0810
Personal Care Attendant Qualifications 410–172–0820
Provider Termination 410–172–0830
Personal Care Attendant Service Assessment, Authorization, and Monitoring 410–172–0840
Personal Care Attendant Payment Limitations 410–172–0850
Telemedicine for Behavioral Health 410–172–0860
Billing for Dual Eligible Individuals
Last Updated

Jun. 8, 2021

Rule 410-172-0620’s source at or​.us