2.12.4.2

Documentation Requirements

Documentation elements are routinely assessed for compliance in retrospective review of client records, including 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.

•	All attendants’ arrival and departure times are documented with signature and time.

•	Documentation of services correlates with, and reflects medical necessity for, the services provided on any given day.

•	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.