OAR 410-133-0320: Documentation and Recordkeeping

(1) The school medical provider is responsible for recordkeeping and documentation in adherence to federal, state, and local laws and regulations including OAR 410-120-1360. (2) Documentation for school-based health services: (a) Is a combination of education requirements, service documentation by SBHS-recognized providers, and the IPOC, when applicable. (b) Planned services require an IPOC and service documentation, in adherence to federal, state, and local laws and regulations including OAR 410-120-1360 and OAR 410-133-0320. (c) Unplanned services require service documentation, in adherence to federal, state, and local laws and regulations including OAR 410-120-1360 and OAR 410-133-0320. (d) Must include: (A) Date of service; (B) Medicaid-enrolled child or young adult’s: (i) Full name; (ii) Medicaid ID; and (iii) Diagnosis code(s); (C) Name of the school medical provider; (D) Name of the rendering provider performing the service; (E) Name of the healthcare provider supervising the service (when applicable); (F) Medically necessary and appropriate need for the service; (G) Location and duration of the service; and (H) Nature, extent, or units of service. (3) Service documentation must be documented within the rendering provider’s respective scope of practice and in compliance with their respective board rules and requirements, OAR 410-133-0120, and OAR 410-120-1360. (4) Recordkeeping for school-based health services provided by SBHS-recognized providers must: (a) Include information necessary to support each health service billed by the school medical provider including: (A) If applicable, the child or young adult’s IPOC including any addendum to the IPOC that correlates with the covered health services provided and reimbursed; (B) If applicable, the Section 504 Accommodation Plan associated with the IPOC; and (C) Service documentation recorded by the SBHS-recognized provider. (b) Be retained by the school medical provider in compliance with OAR 410-120-1360.