Record Keeping

​Documentation must be maintained which shows that services provided to, or on behalf
of, the student billed, comply with the MDHHS policy. These rules state that the following
information should be documented and maintained for eight (8) years:

  • The IEP/IFSP document with goals and services identified and any addendum to the plan.

  • Relevant evaluations and assessments given to determine the need for services.

  • Annual prescriptions, referrals or orders for services

  • A progress note/record notation for each direct service including: the student's name and birth date; date of service/treatment; type(modality) of service/treatment, and the student's response to that day's service/treatment; the name and title of the person providing the service/treatment and a dated signature.

  • Monthly progress summary which is a summation of the progress notes and must include: evaluation of student's progress toward his/her goals and objectives in the plan of care, changes in medical or mental status; and changes in treatment with rationale for change.

  • A record notation for each date of targeted case management activity that occurred throughout the month on the student's behalf. The record must clearly reconstruct the case management activity with a detailed description of services. The service note or monthly summary must include the actual dates the services were provided and include the student's name and birth date, the name and title of the person providing the service and a dated signature.

Each clinician or local school district must maintain legible, written or electronic​ records/documentation to support the provision of the service and the subsequent reimbursement by Medicaid. You must maintain documentation verifying that dates billed on Medicaid records accurately reflect the dates that services were rendered. The dates of consultations with staff and/or family must be maintained in your records. Oakland Schools archives all electronic billing information for a minimum of eight (8) years.​