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3.9.3.12 Documentation of Services Provided/Retrospective Review
Documentation elements that are routinely assessed for compliance in retrospective review of client records include, but are not limited to, the required documentation noted above, as well as the following:
• All entries are legible to people other than the author, dated (month, day, year, time), and signed by the author.
•Each page of the record documents the client's name and Medicaid identification number.
•Client assessment time is documented at the beginning of each shift.
•All nurses' arrival/departure times are documented with signature and time in the narrative section of the nurses' notes.
•Entries are dated and timed every 1 to 2 hours.
•The name of the medication, dose, route, time given, client response, and other pertinent information is recorded when medication is administered.
•The name of treatment, time given, route or method used, client response, and other pertinent information is provided when treatments are administered.
•The amount, type, times given, route or method used, client response, and other pertinent information is provided when feedings are administered.
•The POC and documentation of services correlate with and reflect medical necessity for the services provided on any given day.
•A request for prior authorization must include documentation from the provider to support the medical necessity of the service, equipment, or supply.
•Client's arrival or departure from the home setting is documented with the time of arrival, departure, mode of transportation, and who accompanied the client.
•Documentation of teaching the client or the client's responsible adult includes the length of time, the subject of the teaching, the understanding of the subject matter by the person receiving the teaching, and other pertinent information.
•Supervisory visits include specifics of the visit.
•If a client is receiving skilled nursing services through another program or service in addition to CCP, such as MDCP, each provider's shift notes designate specifically which type of service they are providing during that shift.
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