Library: Policy

317:30-5-209. Documentation

Issued 11-1-07

     All services must be reflected by documentation in the patient records.  All assessment and treatment services must include the following:

• (1) date;

• (2) start and stop time for each timed treatment session;

• (3) signature of the service provider;

• (4) credentials of service provider;

• (5) documentation of the referral source;

• (6) problems(s), goals and/or objectives identified on the treatment plan;

• (7) methods used to address the problem(s), goals and objectives;

• (8) progress made toward goals and objectives;

• (9) patient response to the session or intervention; and

• (10) any new problem(s), goals and/or objectives identified during the session.