Conn. Agencies Regs. § 17b-262-700

Current through December 27, 2024
Section 17b-262-700 - Documentation
(a) The provider shall maintain a client file that shall include, but not be limited to, the following information:
(1) identifying data:
(A) name of client;
(B) address;
(C) date of birth;
(D) gender; and
(E) Medicaid identification number;
(2) name, address, telephone number and license number of the public health dental hygienist responsible for the dental care;
(3) pertinent past and current health history of the client; and
(4) the medical record for the client.
(b) All notes and reports in the client's medical record shall be type written or legibly written in ink or maintained electronically, dated and signed by the recording person with his or her full first name or first initial, surname and title. Electronic signatures shall be permissible in accordance with state and federal law.
(c) Each public health dental hygienist shall document action taken to:
(1) refer for treatment any client with needs outside the public health dental hygienist's scope of practice;
(2) coordinate such referral for treatment to dentists; and
(3) provide meaningful medical and dental information to dentists to whom clients are referred.
(d) For fluoride treatments provided to a client pursuant to section 17b-262-697(b)(2)(B)(i) of the Regulations of Connecticut State Agencies, the provider shall maintain documentation substantiating that the client is using radiology services as oncology treatment on a regular basis.
(e) All required documentation shall be maintained for at least five (5) years or longer as required by state or federal law in the provider's file and shall be subject to review by the authorized department personnel. In the event of a dispute concerning a service provided, documentation shall be maintained until the end of the dispute, for five (5) years, or the length of time required by state or federal law, whichever is greatest.
(f) Failure to maintain and provide all required documentation to the department upon request may result in the disallowance and recovery by the department of any future or past payments made to the provider.

Conn. Agencies Regs. § 17b-262-700

Adopted effective July 10, 2001