Subsection 144-101-II-30.06 - POLICIES AND PROCEDURES30.06-1Professional and Other Qualified StaffA. Physicians employed by a family planning agency may provide family planning medical and counseling services by virtue of possession of a current license to practice medicine in the State or Province in which the services are performed. Each agency shall employ a physician to provide medical direction for the agency's health care activities and counseling and for medical supervision of the health care staff.
B. A physician assistant may provide family planning, medical and counseling services when he or she has obtained Full or Temporary Licensure from the Board of Licensure in Medicine or Osteopathy, which must be renewed bi-annually in accordance with Board rules. Such services may be performed only when delegated by a physician in accordance with the rules and regulations governing physician assistants.C. A family planning nurse practitioner or certified nurse-midwife may provide family planning, medical and counseling services which are supported by written protocols when he or she is a graduate of a certified nurse practitioner program with specialization in Family Planning, Obstetrics-Gynecology, Women's Health Care or its equivalent and when he or she holds a current nurse practitioner or nurse-midwife license to practice in the State or Province in which services are provided.D. A licensed dietitian may provide dietary counseling, dietary instruction and other nutritional services when employed by a family planning agency and when he or she is licensed by the Board of Licensing of Dietetic Practice in the State or Province in which services are provided.E. A family planning specialist may provide counseling, instruction, and other support services under the coordination and oversight of a family planning nurse practitioner, certified nurse-midwife, physician or physician assistant when he or she has had at least 1 year of experience in a related setting, or at least 1 year of education in a relevant field. In addition, there must be documentation of successful completion of a family planning agency's formal training and orientation program in each family planning specialist's record. Those family planning specialists employed by a family planning agency prior to June 1, 1987, shall be deemed qualified to provide services if, for such persons, documentation of related training and prior experience is present.
30.06-2Member's RecordsThere shall be a specific record for each member which shall include, but not necessarily be limited to:
A. The member's name, address, and birthdate; B. The member's medical and social history, including immunization records, as appropriate;C. A description of the findings from the physical examination;D. Long and short range medical goals, as appropriate;E. A description of any tests ordered and performed and their results;F. A description of treatment, counseling, or follow-up care provided and the dates scheduled for revisits;G. Notation of any medications and/or supplies dispensed or prescribed;H. Recommendations for and referral to other sources of care;I. The dates on which all services were provided; andJ. Written progress notes, which shall identify the services provided. Other qualified staff (woman's specialists, educators, etc.) may sign record entries relative to history taking and up-dates, instruction, and pregnancy testing and results.
Entries are required for each date of service billed and must include the name, title, and signature of the service provider.
30.06-3Program IntegrityA. Program Integrity monitors the medical services provided and determines the appropriateness and necessity of the services B. The Department and its professional advisors regard the maintenance of adequate clinical records as essential for the delivery of quality care. In addition, providers should be aware that clinical records are key documents for post-payment audit. In the absence of proper and complete clinical records, no payment will be made, and payments previously made may be recovered in accordance with Chapter I of this manual.C. Upon request, the provider will furnish to the Department, without additional charge, the clinical records, or copies thereof, corresponding to and substantiating services billed by that provider.D. The Department requires that clinical records (originals or copies) and other pertinent information will be transferred, upon request and with the member's signed release of information, to other clinicians involved in the member's care. C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-30, subsec. 144-101-II-30.06