OAR 411-300-0190: CIIS Provider Documentation and Records

(1) Documentation of services provided must be consistent with the requirements described in: (a) OAR 411-450-0080 for community living supports. (b) OAR 411-375-0035 for independent providers. (2) Documentation of private duty nursing services must comply with OAR chapter 851 (Oregon State Board of Nursing) and must include all of the following: (a) The name of the child or young adult on each page of documentation. (b) The date of service. (c) Time of start and end of service delivery by each provider. (d) Anything unusual from the Nursing Service Plan expanded in the narrative. (e) Interventions. (f) Outcomes, including the response of the child or young adult to services delivered. (g) Nursing assessment of the status of the child or young adult and any changes in that status per each working shift. (h) Full signature of the provider.