Documentation Requirements

Documentation Requirements A. The Division of Medicaid requires providers of swing bed services to maintain auditable records that substantiate the services provided. Refer to Maintenance of Records Part 200, Ch.1, Rule 1.3. At a minimum, the records must contain the following on each beneficiary: 1. Date of service, 2. History and physical exam, with update if necessary, 3. Physician’s progress notes, 4. Medical indication, 5. Results and finding of all diagnostic and lab procedures, 6. Treatment rendered, 7. Provider’s signature or initials, 8. Documentation of services consisting of skilled nursing care and related services for patients requiring medical or nursing care, 9. Documentation of rehabilitation services for the rehabilitation of injured, disabled or sick persons, and 10. Frequent documentation of health related care and services to individuals who, because of their medical status, require care and services above the level of room and board which can be made available only through institutional facilities.