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Learn key documentation rules, scope of service, clear objective writing, and documentation requirements in this comprehensive training to enhance DSP documentation skills.
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Training and Coaching DSPs for Excellence in Documentation April 2019
What we will cover • What is important for you to know • Rule/Manual References • Scope of Service • Well written plans = Good documentation • Documentation Requirements • Training Resources • Documentation Template • Skills • Guide
Rules/Manuals As a person charged with teaching documentation it is imperative that you know the rules. Administrative Rules & Provider Manuals
Scope of Service It is critical that you understand the components of each service you are providing. They can be found both in IAC and the provider manual.
Scope of Service - Provider Manuals HCBS Provider Manual - Pages 27-90d Habilitation Manual - Pages 22 - 50a
Well Written Plans = Good Documentation
If you missed our Webinar: Writing A Strong Service Plan, it is available on IACP Website This will give your staff information on how to write objectives that will assist your staff in writing good documentation.
Clear Objective = Yes to these Questions Are the conditions clear so everyone knows how or when this is to be worked on? Is the behavior something I can SEE? (overt skill) Is the skill really the behavior I want to see changed? Is it written for the client not the staff? Is it specific to 1 skill-not compounded? Do I have enough performance criteria so that it’s not a 1 and done type objective? Is it positive and strength based?
Documentation Requirements IAC 79.3 & Provider Manuals
HCBS Manual The record for each service provided shall include information necessary to substantiate that the service was provided and shall include the following: • The specific procedures or treatments performed. • The complete date of the service, including the beginning and ending date if the service is rendered over more than one day.
HCBS Manual • The complete time of the service, including the beginning and ending time (including AM and PM designation) if the service is billed on a time-related basis. • The location where the service was provided • The name, dosage, and route of administration of any medication dispensed or administered as part of the service.
HCBS Manual • Any supplies dispensed as part of the service. • The first and last name and professional credentials, if any, of the person providing the service. The signature of the person providing the service, or the initials of the person providing the service if a signature log indicates the person’s identity.
HCBS Manual • For 24-hour care, documentation for every shift of the services provided, including the member’s response to the services provided and the person who provided the services.
Habilitation Manual The provider’s file for each Medicaid member must include progress notes for each date of service that detail specific services rendered related to the covered habilitation service for which a claim is submitted to the Iowa Medicaid program.
Habilitation Manual The following items must be included in each progress note entry, for each Medicaid member, and for each date of service: • The date and amount of time services were delivered, including the beginning and ending time of service delivery.
Habilitation Manual • The first and last name and title of provider staff actually rendering service, as well as that person’s signature. • The place of service (i.e., location where service was actually rendered).
Habilitation Manual • A description of the specific components of the Medicaid-payable habilitation service being provided (using service description terminology from the covered services section of this manual). • The name, dosage, and route of administration of any medication administered, when it is a part of the service.
Habilitation Manual • The nature, extent, and number of units of the habilitation service that was rendered. The progress note must describe what specifically was done, and include the progress and barriers to achieving the goals and objectives as stated in the member’s comprehensive service plan.
Training Resources
Develop Training Resources for your staff • List the scope of service for each service they will be providing. • Develop a Q & A document • Assure they understand each member’s service plan. • Develop an FAQ for documentation
Develop Training Resources for your staff • Use common intervention terminology. • Develop a template that gives them the pattern to write good documentation. • Have a uniform way to train all DSP and direct line supervisors.
FAQ Example Q. When do I need to complete documentation? A. Within 24 hours after providing the service. (you must never document prior to providing a service, doing so would be considered fraud)
FAQ Example Q. How much should I document? A. Documentation Must Support the service… • ASK: Is what’s documented something that should take that amount of time? • ASK: Does my note clearly show that I provided support/skill building throughout a shift? • Your notes need to have in it what’s necessary but they don’t need to be full length documentaries.
FAQ Example Q. If I am working with 4 members, is it ok to copy documentation from one to another as they all were involved in the same activity? A. NO! Documentation must be specific to the person and the encounter – cutting and pasting...NEVER allowed. Don’t do it. This includes cutting and pasting documentation for one member for one day to the next.
FAQ Example Q. What is a good note? A. Ask yourself: If I read this tomorrow or next week would I: • Be able to see what skill the staff supported the member in? • Be able to see how I, as staff, supported the member’s need. • Be able to see how the member responded to that support? • Be able to see if the member made progress with that intervention? • Be able to see that the services authorized in the member’s service was implemented If the answer is YES to these questions, you wrote a good note.
