Documentation Requirements

Documentation Requirements The hospital must maintain legible and auditable records that will substantiate the claim submitted to Medicaid. At a minimum, the records must contain the following on each patient: A. Date of service. B. A comprehensive history and physical assessment/report, including the patient’s presenting complaint. C. Diagnosis(es) to substantiate the hospitalization and all treatments/procedures rendered during the hospitalization. D. The specific name/type of all diagnostic studies, including lab, x-ray, and the like, and the medical indication and results/finding of the studies. E. Documentation and consult reports to substantiate treatment/procedures rendered, the patient’s response to the treatment/procedure; and the signature or initials of the appropriate health care worker providing the treatment/procedure, including but not limited to the physician, nurse, therapist, dietitian. F. The name, strength, dosage, route, either IM, IV, PO, topical, enteral, intracatheter, date and time, indication for, and the administration of all medications administered to the patient. G. Discharge planning and instructions, including the signature or initials of the health care worker performing the instruction; the name of the person being instructed; date and time of instruction; whether the instructions are given in writing, verbally, by telephone or other means; and how much instruction was comprehended by the beneficiary, including level of proficiency on return demonstration when a procedure is being taught. H. Discharge orders for medications, treatments and procedures that indicate whether the orders/prescriptions are issued in writing, verbally, or by telephone, and to whom the orders are issued. I. Signed physician orders for all medications, treatments, and procedures rendered to the patient. J. All x-ray images, including films and digital images, films, and digital images must be of such quality that they can be clearly interpreted.