This section applies to providers, as defined under WAC
182-500-0085 and under WAC
182-538-050. Providers
must:
(1) Maintain documentation in
the client's medical or health care records to verify the level, type, and
extent of services provided to each client to fully justify the services and
billing, including, but not limited to:
(a)
Client's name and date of birth;
(b) Dates of services;
(c) Name and title of person performing the
service;
(d) Chief complaint or
reason for each visit;
(e)
Pertinent past and present medical history;
(f) Pertinent findings on examination at each
visit;
(g) Medication(s) or
treatment prescribed and/or administered;
(h) Name and title of individual prescribing
or administering medication(s);
(i)
Equipment and/or supplies prescribed or provided;
(j) Name and title of individual prescribing
or providing equipment and/or supplies;
(k) Detailed description of treatment
provided;
(l) Subjective and
objective findings;
(m) Clinical
assessment and diagnosis;
(n)
Recommendations for additional treatments, procedures, or
consultations;
(o) Radiographs (X
rays), diagnostic tests and results;
(p) Plan of treatment and/or care, and
outcome;
(q) Specific claims and
payments received for services;
(r)
Correspondence pertaining to client dismissal or termination of health care
practitioner/patient relationship;
(s) Advance directives, when required under
WAC
182-501-0125;
(t) Patient treatment agreements (examples:
Opioid agreement, medication and treatment compliance agreements);
and
(u) Informed consent
documentation.
(2) Keep
legible, accurate, and complete charts and records;
(3) Meet any additional record requirements
of the department of health (DOH);
(4) Assure charts are authenticated by the
person who gave the order, provided the care, or performed the observation,
examination, assessment, treatment or other service to which the entry
pertains;
(5) Make charts and
records available to the medicaid agency, its contractors or designees, and the
United States Department of Health and Human Services (DHHS) upon request, for
six years from the date of service or longer if required specifically by
federal or state law or regulation. The agency does not separately reimburse
for copying of health care records, reports, client charts and/or radiographs,
and related copying expenses; and
(6) Permit the agency, DHHS, and its agents
or designated contractors, access to its physical facilities and its records to
enable the agency and DHHS to conduct audits, inspections, or reviews without
prior announcement.
