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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: 8/6/24

Page updated: 1/20/26

Legal authority

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

Overview

To receive payment for providing EIDBI services, the provider agency and its staff must follow guidelines for health service records as a condition of Minnesota Health Care Programs (MHCP), including:

  • · Maintain a health service record for every person the agency serves.
  • · Document in the record every EIDBI service delivered to the person and their family.
  • · Ensure documentation complies with Minn. R. 9505.2175 and Minn. R. 9505.2197.
  • · Comply with any data requests, consistent with the Minnesota Government Data Practices Act (Minn. Stat. §256B.27 and Minn. Stat. §256B.064).
  • · Meet all additional MHCP provider requirements for health service records and record-keeping.

    • DHS will recover payments made to the provider agency for EIDBI services that are not documented in the person’s health service record.

    Requirements

    A qualified supervising professional (QSP) is responsible to supervise and review all EIDBI services and documentation, including case notes and incident reports.

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

  • · Personal information for the person and their legal representative.
  • · Contact information for the QSP and other primary treating provider(s), including phone numbers.
  • · Information about other services the person or legal representative 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 legal representative(s).
  • · Completed and current Individual Treatment Plan (ITP), DHS-7109 (PDF), including ITP and Progress Monitoring Week-in-the-Life Schedule (Addendum C), DHS-7109C (PDF), with signatures from the QSP and legal representative(s).
  • · Documented preferences of the parent(s) and/or primary caregiver(s) for EIDBI services, including their level of involvement, as identified in the ITP.
  • · Plan for how to provide clinical supervision and observation and direction to individual providers, when required and as identified in the ITP.
  • · Progress monitoring notes, data and summary results.
  • · Transition and termination plan, as identified in the person’s ITP.
  • · Your Rights and Responsibilities, DHS-7645A (PDF) signed by the person and/or legal representative, QSP and interpreter, if applicable.
  • · Provider Agency Responsibilities, DHS-7645B (PDF) signed by the person and/or legal representative, QSP and interpreter, if applicable.
  • · Case notes (refer to the section below).
  • · Additional, ongoing documentation (refer to the section below).
  • · Incident reports (refer to the section below).

    • The provider agency must update this information in the person’s health service record as applicable and necessary.

    Case notes

    The provider must create a case note to document the service delivery:

  • · Each time the provider delivers an EIDBI service to the person or legal representative.
  • · Each time a service stops and restarts. This includes any breaks and unbillable time.

    • Specificity

    Case notes should be specific to EIDBI services and should not include case notes from other services the person might receive (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).

    • Requirements

    Each case note must be legible and include:

  • · Person’s name.
  • · Type of service provided (e.g., individual or group intervention, observation and direction, parent training).
  • · Name, title (e.g., QSP, level I) and signature of the provider who delivered the service.
    Note: The only required signature is that of the provider who delivered and, therefore, is billing for the service.
  • · Date the service was provided.
  • · Date the provider added the documentation in the person’s health service record.
  • · Session start and stop times.
  • · Summary of the person’s progress or response to treatment and any changes in the treatment or diagnosis.

    • Information to include when applicable

    A case note also might include:

  • · Coordination with or referrals to other professionals, including each professional’s name and date of contact.
  • · Current significant events the person might be experiencing.
  • · Documentation of supervision.
  • · Emergency interventions used.
  • · New behaviors or symptoms.
  • · Parent/primary caregiver concerns.
  • · Protocol modification.
  • · Summary of treatment effectiveness, prognosis, discharge planning, etc.
  • · Test results and medications.

    • Additional, ongoing documentation

    The provider should promptly document all the following in the person’s health service record, when applicable:

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

    • The provider agency must maintain these records for five years, in accordance with Minn. R. 9505.2190.

    Incident reports

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

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

    Examples of incidents

    An incident can include but is not limited to:

  • · Bump or blow to the head.
  • · Illness, accident or injury that requires first aid treatment.
  • · Unusual or unexpected event that jeopardizes the safety of the person or staff member, including the person leaving the agency unattended (i.e., bolting, elopement).
  • · Emergency use of manual restraint (refer to the emergency use of manual restraint section of EIDBI – Rights and responsibilities).

    • What to include in the report

    The incident report should include:

  • · Incident description.
  • · Staff member response.

    • Additional resources

    EIDBI – Clinical supervision
    EIDBI – QSP qualifications, roles and responsibilities
    EIDBI – Rights and responsibilities
    EIDBI – Services
    MHCP Provider Manual – Provider basics – Health service records
    MHCP Provider Manual – Provider basics – Record-keeping

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