Or. Admin. Code § 410-133-0320

Current through Register Vol. 63, No. 12, December 1, 2024

Section 410-133-0320 - Documentation and Record Keeping Requirements

(1) The school medical provider is responsible for record keeping and documentation in adherence to federal, state, and local laws and regulations including OAR 410-120-1360.

(2) Documentation for School-Based Health Service (SBHS) provided by medically-qualified individuals must:

(a) Be documented within the medically-qualified individual's respective scope of practice and in compliance with their respective board rules and requirements and OAR 410-120-1360.

(b) Include the child or young adult's diagnosis, medically necessary and medically appropriate need for the service, date of service, location and duration of service delivery, name of the medically-qualified individual performing the service, name of the supervisory medically-qualified individual supervising the service (when applicable), and the full name and Medicaid ID of the child or young adult receiving the service.

(c) Be annotated each time a service is provided and signed or initialed by the individual who provided the service or shall clearly indicate the individual who provided the service.

(3) Recordkeeping for SBHS provided by medically-qualified individuals must include:

(a) Information necessary to support each health service billed by the school medical provider pursuant to a child or young adult's Individual Plan of Care (IPOC) including:

(A) The child or young adult's IPOC including any addendum to the IPOC that correlates with the covered health services provided and reimbursed;

(B) If applicable, the Individual Education Program (IEP), Individualized Family Service Plan (IFSP), or Section 504 Accommodation Plan associated with the IPOC; and

(C) Service documentation recorded by the performing medically-qualified individual.

(b) Records and documentation must be retained by the school medical provider in compliance with OAR 410-120-1360.

Or. Admin. Code § 410-133-0320

HR 39-1991, f. & cert. ef. 9-16-91; HR 22-1995, f. & cert. ef. 12-1-95; OMAP 31-2003, f. & cert. ef. 4-1-03; OMAP 53-2003, f. 8-13-03 cert. ef. 9-1-03; OMAP 24-2005(Temp), f. & cert. ef. 4-5-05 thru 10-1-05; OMAP 53-2005, f. 9-30-05, cert. ef. 10-1-05; DMAP 19-2009, f. 6-12-09, cert.ef. 7-1-09; DMAP 33-2016, f. 6-29-16, cert. ef. 7/1/2016; DMAP 121-2024, amend filed 09/06/2024, effective 9/6/2024

Statutory/Other Authority: ORS 413.042

Statutes/Other Implemented: ORS 414.065