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Early Intensive Development and Behavioral Intervention Manual

Early Intensive Development and Behavioral Intervention Manual

Health service records

Page posted: 2/17/17

Page reviewed: 11/4/26

Page updated: 11/4/26

Legal authority

Minn. R. 9505.2175, Minn. R. 9505.2197, Minn. R. 9505.2190, Minn. Stat. §256B.27, Minn. Stat. §256B.064, Minn. Stat. §256B.0949, Minn. Stat. §245D.02, subd. 8(a)

Definitions

Incident: Any of the following situations:

  • · A person has an illness, accident or injury that requires first aid.
  • · A person experiences a bump or blow to the head.
  • · An unusual or unexpected event jeopardizes the safety of a person or employee, including when a person leaves the agency unattended.

    • Incident report: Documentation the provider completes when an incident occurs during service delivery. The incident report describes the event and provider response.

    Progress notes: Documentation the provider must complete each time they deliver an EIDBI service. Progress notes must describe the service provided and how it relates to the person’s treatment plan.

    Overview

    Minnesota Health Care Programs (MHCP) requires EIDBI providers to maintain a complete, accurate health service record for each person receiving EIDBI services. The health service record:

  • · Documents all EIDBI services delivered.
  • · Supports medical necessity.
  • · Demonstrates compliance with EIDBI service, authorization and billing requirements.
  • · Contains all applicable records, documentation and forms related to EIDBI services.

    • This page explains:

  • · Health service record required components.
  • · Progress note requirements.
  • · Incident report requirements.

    • For general documentation requirements and more information, refer to EIDBI – Overview of EIDBI documentation.

    For specific documentation requirements for health service records, progress notes and incident reports, refer to the sections below.

    Required components of the health service record

    EIDBI providers must:

  • · Include the person’s name on each page of the health service record.
  • · Document clinical supervision in the health service record.

    • Required forms

    Each person’s health service record must include all the following completed forms:

  • · Comprehensive Multi-Disciplinary Evaluation (CMDE), DHS-7108 (PDF).
  • · Individual Treatment Plan (ITP), DHS-7109 (PDF).
  • · Your Rights and Responsibilities, DHS-7645A (PDF).
  • · Provider Agency Responsibilities, DHS-7645B (PDF).

    • Each person’s health service record also must include the following completed forms, when applicable:

  • · ITP and Progress Monitoring Week-in-the-Life Schedule (Addendum C), DHS-7109C (PDF).
  • · Incident reports.
  • · EIDBI Safety Plan Template, DHS-7109F.
  • · EIDBI Transition and/or Discharge Summary, DHS-7109A.

    • Note: Completed forms must include signatures from the person or their legal representative, CMDE or QSP provider and interpreter, when applicable.

    Progress note requirements

    The provider must complete a progress note for each billable EIDBI service provided. Each progress note must include:

  • · The person’s name.
  • · The type and date of service provided.
  • · Start and stop times for the service.
  • · The setting of service delivery (e.g., in-home, center, telehealth)
  • · The provider’s full name, title, credentials, signature and date.
    Note: The provider must complete the progress note within 72 hours of service delivery or explain any delay.
  • · The specific covered service activity provided and the purpose of the service, including the treatment goal, objective or skill area addressed.
  • · Descriptions of the interventions or activities provided and the person’s response to them.
  • · Documentation of travel time associated with the service, when applicable.
  • · Documentation of caregiver involvement and coordination of care, when applicable.

    • Incident report requirements

    Providers must complete an incident report if an incident occurs.

    Incident reports must:

  • · Describe what occurred and how staff responded.
  • · Document prompt notification to the person’s legal representative.
  • · Be completed by the agency staff member in charge of the person.
  • · Be completed as soon as possible after the incident occurs to support continuity of care, safety and compliance.
  • · Be retained by the agency for at least five years from the date of the incident report.

    • Additional resources

    EIDBI – Overview of EIDBI documentation
    EIDBI – Clinical supervision
    EIDBI – Staff supervision
    EIDBI – QSP qualifications, roles and responsibilities
    EIDBI – Rights and responsibilities
    EIDBI – Services
    EIDBI – Personnel records
    EIDBI – How to complete CMDE Medical Necessity Summary Information, DHS-7108
    EIDBI – How to complete ITP and Progress Monitoring, DHS-7109
    MHCP Provider Manual – Provider basics – Health service records
    MHCP Provider Manual – Provider basics – Record-keeping

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