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PDFWAC 182-502-0020

Health care record requirements.

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.
[Statutory Authority: RCW 41.05.021 and 42 C.F.R. 455. WSR 13-03-068, § 182-502-0020, filed 1/14/13, effective 2/14/13. WSR 11-14-075, recodified as § 182-502-0020, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.080, and 74.09.290. WSR 11-11-017, § 388-502-0020, filed 5/9/11, effective 6/9/11. Statutory Authority: RCW 74.08.090, 74.09.500, and 74.09.530. WSR 01-07-076, § 388-502-0020, filed 3/20/01, effective 4/20/01; WSR 00-15-050, § 388-502-0020, filed 7/17/00, effective 8/17/00.]
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