Oregon Department of Human Services, Aging and People with Disabilities and Developmental Disabilities

Rule Rule 411-380-0080
Provider Documentation and Records


(1)

Documentation of direct nursing services must be written in an accurate, timely, thorough, and clear manner.

(2)

Documentation must comply with OAR chapter 851 and must include all of the following:

(a)

The name of the individual on each page of documentation.

(b)

The date of service.

(c)

Time of start and end of service delivery by each provider.

(d)

Anything unusual from the standard plan of care expanded in the narrative.

(e)

Interventions.

(f)

Outcomes, including the response of the individual to services delivered.

(g)

Nursing assessment of the status of the individual and any changes in that status per each working shift.

(h)

Full signature of the provider.

(3)

Documentation of provided direct nursing services must be sent to the case management entity upon request or as outlined in the ISP and maintained in the home, foster home, 24-hour residential setting, or the place of business of the provider of services.

(4)

Providers must furnish requested documentation immediately upon the written request from the Department, the Oregon Department of Justice Medicaid Fraud Unit, OHA, Centers for Medicare and Medicaid Services, or their authorized representatives, or within the timeframe specified in the written request. Failure to comply with the request may be considered by the Department as reason to deny or recover payments.

(5)

Access to records by the Department including, but not limited to, medical, nursing, behavior, psychiatric, or financial records, to include providers and vendors providing goods and services, does not require authorization or release by the individual or the legal representative of the individual.

(6)

Per OAR 410-120-1360 (Requirements for Financial, Clinical and Other Records)(2)(e), providers must:

(a)

Retain billing forms, timesheets, and financial records for at least five years from the date of service; and

(b)

Retain clinical record documentation of provided services for at least seven years from the date of service.
Source

Last accessed
Jun. 8, 2021