Or. Admin. Code § 410-172-0620 - Documentation Standards
(1) OHP
providers shall maintain records that fully support the extent of services for
which payment has been requested and provide the records to the Division upon
request.
(2) All records shall
document the specific service provided, the number of services comprising the
service provided, the extent of the service provided, the dates on which the
service was provided, and the individual who provided the service.
(3) Clinical records shall document the
recipient's diagnosis and the medical need for the service.
(4) The record shall be annotated each time a
service is provided and be signed or initialed by the individual providing the
service.
(5) Information contained
in the record shall be appropriate in quality and quantity to meet the
professional standards applicable to the provider and any additional standards
for documentation found in these rules, other Division rules, and pertinent
contracts.
(6) For AMH certified
providers, in addition to meeting the requirements in this rule, clinical
documentation for behavioral health services shall also comply with the
requirements in OAR 309-019-0135 through OAR
309-019-0140, and clinical
documentation standards for substance use disorder services shall comply with
OAR 309-018-0140 through OAR
309-018-0150.
Notes
Stat. Auth.: ORS 413.042, 430.640, 430.705, & 430.715
Stats. Implemented: ORS 414.025, 414.065, & 430.640
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