Library: Policy

317:30-5-3. Documentation of services

Issued 7-27-95

     Records in a physician's office or a medical institution (hospital, nursing home or other medical facility), must contain adequate documentation of services rendered.  Such documentation must include the physician's signature or identifiable initials in relation to every patient visit, every prescription, or treatment.  In verifying the accuracy of claims for procedures which are reimbursed on a time frame basis, it will be necessary that documentation be placed in the patient's chart as to the beginning and ending times for the service claimed.