Or. Admin. R. 410-132-0070 - Documentation Requirements

(1) Documentation of services provided shall be maintained in the client's place of residence by the private duty nurse until discharged from service. Payment may not be made for services where the documentation does not support the definition of skilled nursing. Documentation shall meet the standards of the Oregon State Board of Nursing.
(2) The private duty nurse shall ensure completion and documentation of a comprehensive assessment of the client's capabilities and needs for nursing services within seven days of admission. Comprehensive assessments shall be updated and submitted to the responsible unit by the next work day after any significant change of condition and reviewed by the responsible unit within the Oregon Health Authority at least every 60 days. Some examples of significant change in condition are hospital admission, emergency room visit, and change in status, death, or discharge from care.
(3) The nursing care plan shall document that the private duty nurse, through case management and coordination with all interdisciplinary staff and agencies, provides services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each client in accordance with a written, dated, nursing care plan. The nursing care plan shall:
(a) Be completed within seven days after admission for children and adolescents with short-term needs who are served through the Division. The nursing care plan shall be reviewed, updated, and submitted whenever the client's needs change, but at least every 60 days;
(b) Describe the medical, nursing, and psychosocial needs of the client and how the private duty nurse will actively coordinate and facilitate meeting those needs. This description of needs shall include interventions, measurable objectives, goals, and time frames in which the goals and objectives will be met and by whom;
(c) Include the rehabilitation potential including functional limitations related to Activities of Daily Living (ADL), types and frequency of therapies, and activity limitations per physician order;
(d) Include services related to school-based care according to the IEP and the Individualized Family Service Plan, if applicable;
(e) Show coordination of all services being provided including, but not limited to, the client or representative, registered nurse (RN) case manager, Department case worker, physician, other disciplines involved, and all other care providers involved in the client's treatment plan;
(f) Include a statement of the client's potential toward discharge. Timelines shall be included in the plan outline;
(g) Be available to and followed by all caregivers involved with the client's care.
(4) Documentation of private duty shift care and responses to care shall be written in an accurate, timely, thorough, and clear manner on the narrative or flow sheet. Documentation shall comply with the requirements of the Oregon State Board of Nursing in OAR chapter 851 and shall include:
(a) The name of the client on each page of documentation;
(b) The date of service;
(c) Time of start and end of service delivery by each caregiver;
(d) Anything unusual from the standard plan of care shall be expanded on the narrative;
(e) Interventions;
(f) Outcomes including the client's response to services delivered;
(g) Nursing assessment of the client's status and any changes in that status per each working shift; and
(h) Full signature of provider.
(5) Documentation of delegation, teaching, and assignment shall be in accordance with the Oregon State Board of Nursing Rules.
(6) For documentation to be submitted with prior authorization, see OAR 410-132-0100.

Notes

Or. Admin. R. 410-132-0070
HR 6-1997, f. & cert. ef. 2-19-97; OMAP 16-2000, f. 9-28-00, cert. ef. 10-1-00; DMAP 45-2015, f. & cert. ef. 8/25/2015

Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

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