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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.

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