OAR 410-152-0020: Documentation Requirements.

(1) The Plan of Care shall include the individuals need for: safety planning, interest in employment, housing, education, mental health and substance abuse treatment services, gang affiliation, legal needs and history of injury within the last six (6) months. (2) Services rendered must be documented and signed, electronically or wet, by the certified Violence Prevention Professional rendering the service on each date of service. (3) The provider shall maintain a record of each service provided to each eligible individual for each date of service including, but not limited to: (a) Name and Medicaid identification number of individual receiving the service; (b) Name and credentials of the certified Community Violence Prevention professional; (c) Date the service was provided; ( d) Description of each service provided to the individual to address the psychosocial and safety needs of the client to include coordination of all services and interventions as developed in the individuals plan of care. (e) Description of outcomes, including the individual’s responsiveness to services and any change in the frequency of: emergency room visits, retaliatory violence, arrest and acute stress and post-traumatic stress disorder. (f) Document referrals to other identified services and supports, including referrals to entities completing eligibility assessments. (4) The billing provider shall maintain adequate records for all Community Violence Prevention services rendered that fully supports the charges billed. Provider is responsible for the completeness, accuracy and secure storage of financial and clinical records and all other documentation of the specific care, service.