Documentation and Record Maintenance

Documentation and Record Maintenance A. Documentation of each service provided must be in the case record. Refer to Maintenance of Records Part 200, Ch.1, Rule 1.3. B. The entry or service note must include all of the following documentation: 1. Date of service, 2. Type of service provide, 3. Time service began and time service ended, 4. Length of time spent delivering service, 5. Identification of beneficiary(s) receiving or participating in the service, 6. Summary of what transpired during delivery of the service, 7. Evidence that the service is appropriate and approved on the Plan of Care, and 8. Name, title, credential, and signature of individual providing the service. C. Documentation/record maintenance for reimbursement purposes must, at a minimum, reflect the following: 1. Documentation requirements in the CMS approved 1915(i) State Plan Amendment, 2. DMH Operational Standards, 3. Evidence that the service is appropriate and approved on the Plan of Care, and 4. Documentation requirements in the DMH Record Guide.