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Minnesota Department of Human Services Early Intensive Development and Behavioral Intervention Manual
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Health service records

Page posted: 2/17/17

Page reviewed:

Page updated:

Legal authority

Minn. R. 9505.2175, Minn. R. 9505.2197, Minn. Stat. §62J.495, Minn. Stat. §256B.27, Minn. Stat. §256B.064

Overview

In order to receive payment for providing EIDBI services, the EIDBI provider agency and its staff must:

  • • Maintain a health service record for every person it serves
  • • Document in that record every EIDBI service delivered to the person and his or her family
  • • Ensure that documentation complies with Minn. R. 9505.2175 and 9505.2197
  • • Comply with any data requests, consistent with the Minnesota Government Data Practices Act (Minn. Stat. §256B.27 and §256B.064)
  • • Meet additional MHCP provider requirements for health service records and record keeping.
  • DHS will recover payments made to the EIDBI provider agency for EIDBI services that are not documented in the person's health service record.

    Requirements

    Each person’s health service record must include all of the following information, when applicable:

  • • Personal information for the person and his or her parent/legal representative
  • • Contact information (including phone numbers) for QSP and other primary treating provider(s)
  • • Information about other services the person or family receives (to the extent the EIDBI provider agency is aware)
  • • Forms applicable to data privacy
  • • Completed and current Comprehensive Multi-Disciplinary Evaluation (CMDE), DHS-7108 (PDF), with signatures from the CMDE provider and parent/legal representative(s)
  • • Completed and current Individual Treatment Plan (ITP), DHS-7109 (PDF) (including Addendum C, “A typical week in the life of the child”), with signatures from the qualified supervising professional (QSP) and parent/legal representative(s)
  • • Documentation of parent(s)/primary caregiver(s) preference for EIDBI services, including their level of involvement, as identified in the ITP
  • • Plan for providing clinical supervision and observation and direction to individual providers when required and as identified in the ITP; this plan should document how this will be provided
  • • Progress monitoring notes, data and summary results
  • • Transition and termination plan, as specified in the person’s ITP
  • Case notes
  • Additional, ongoing documentation
  • Incident reports.
  • The EIDBI provider agency must update this information in the person’s health service record as applicable and necessary.

    Case notes

    Each time an EIDBI provider delivers an EIDBI service to a person or his or her family, the provider must create a case note to document the service delivery.

    Case notes should be specific to EIDBI services provided and not include case notes from any other services a person may receive in addition to EIDBI (e.g., psychotherapy, CTSS). Case notes for other services:

  • • Should be kept separate from the rest of the person’s EIDBI health services record
  • • Are protected from normal record release under the Health Insurance Portability and Accountability Act (HIPAA).
  • Required

    Each case note must be legible and include:

  • • Type of service provided (e.g., individual or group intervention, observation and direction, parent training, etc.)
  • • Name, title (e.g., QSP, level I, etc.) and signature of provider who delivered the service
  • • Date of service
  • • Date documentation was made in the person’s health service record
  • • Session start and stop times
  • • Scope of service (e.g., treatment modalities used, who was involved, information provided to caregiver, etc.)
  • • Person’s progress or lack of progress on specific goals and objectives, as identified in the ITP
  • • Person’s response or reaction to treatment
  • • Formal or informal assessment of the person’s developmental status.
  • Include when applicable

    A case note also may include the following:

  • • Consultations with or referrals to other professionals, including name of and date of contact with each professional
  • • Current risk factors the person may be experiencing
  • • Emergency interventions used
  • • New behaviors or symptoms
  • • Parent/primary caregiver concerns
  • • Summary of treatment effectiveness, prognosis, discharge planning, etc.
  • • Test results and medications.
  • Additional, ongoing documentation

    Promptly document all of the following in the person’s health service record, when applicable:

  • • Contact with the person’s other providers (e.g., health care, educational, EIDBI), case manager, family members, caregivers and legal representative.
  • • Contact with other individuals interested in the person, including representatives of the courts, corrections systems, or schools. Include the individual’s name and date of each contact.
  • • Required clinical supervision directly related to the person’s services and needs. Include signatures from the supervisor and supervisee.
  • • Meetings to discuss service transition or termination. Include description of the plan, why transition/termination is needed, how it will occur and when it will occur.
  • • Date services are terminated and reasons for termination.
  • Incident reports

    If an incident occurs while a person is receiving services, the agency staff member who was responsible for the person at the time of the incident should complete a report.

    The EIDBI provider agency should keep a copy of all incident reports in the person’s health service record for at least five years from the date of the incident.

    Examples of incidents

    An incident includes the following:

  • • Bump or blow to the head
  • • Illness, accident or injury that requires first aid treatment
  • • Unusual or unexpected event that jeopardizes the safety of a person or staff, including a person leaving the agency unattended (i.e., bolting or elopement).
  • What to include in the report

    The incident report should include:

  • • What happened
  • • How staff responded.
  • Additional provider responsibilities

    A qualified supervising professional (QSP) should supervise and review all health service records, including case notes and incident reports.

    Additional resources

    EIDBI – Administrative and clinical policies for provider agencies
    EIDBI – EIDBI services

    MHCP Provider Manual – Provider basics – health service records

    MHCP Provider Manual – Provider basics – record keeping

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    © 2017 Minnesota Department of Human Services Updated: 2/21/17 2:54 PM | Accessibility | Terms/Policy | Contact DHS | Top of Page | Updated: 2/21/17 2:54 PM