5200, Clinical Policy

Revision 22-3; Effective Nov. 8, 2022

Clinical guidelines are intended to establish minimal expectations of contractor agencies that receive funds to support epilepsy services. In general, specific decisions about tests for diagnostic evaluation, treatment modalities and ongoing follow-up are at the discretion of the clinician in consultation with the client or the client’s family, with the understanding that these decisions will be in line with nationally recognized standards of credible organizations.

Clinical visits to Epilepsy Program providers will be for epilepsy diagnosis and treatment, case management for ongoing care and assistance with integration of personal, social and vocational support services. Therefore, preventive care physical exams and risk assessments are not a requirement in the clinical record for epilepsy clients.

It is an expectation of the Epilepsy Program that epilepsy services providers will encourage each client to receive regular preventive care and health care for any needs other than epilepsy services from an appropriate provider.

5210 Telehealth and Telemedicine

Revision 22-3; Effective Nov. 8, 2022

Epilepsy Program providers may provide services via telehealth, if appropriate. Telehealth services are defined as health care services delivered by a health professional to a patient at a different physical location than the health professional, using telecommunications or information technology.

Providers who offer telehealth and telemedicine medical services must have written policies and procedures that include:

  • clinical oversight by the medical director or designated physician responsible for medical leadership;
  • contraindication considerations for telemedicine use;
  • qualified staff members to ensure the safety of the individual being served by telemedicine at the remote site;
  • safeguards to ensure confidentiality and privacy in accordance with state and federal laws;
  • services are provided by credentialed, licensed clinicians providing clinical care within the scope of their licenses;
  • demonstrated competency by all staff members who are involved in the operation of the system and provision of the services prior to initiating the protocol;
  • quality oversight and monitoring of satisfaction of the individuals served; and
  • management of information and documentation for telemedicine services that ensures timely access to accurate information between the two sites.

5220 Client Health Records and Documentation of Encounters

Revision 22-3; Effective Nov. 8, 2022

Providers must ensure that a patient health record is established for every individual who receives clinical services.

All patient health records must be:

  • complete, legible and accurate documentation of all client encounters, including those by phone, email or text message;
  • written in ink without erasures or deletions, or documented in the electronic medical record (EMR) or electronic health record (EHR);
  • signed by the provider making the entry, including the name of the provider, the provider’s title and the date for each entry;
    • Electronic signatures are allowable to document the encounter or provider review of care.
    • Stamped signatures are not allowable.
  • readily accessible to assure continuity of care and availability to clients; and
  • systematically organized to allow easy documentation and prompt retrieval of information.

All client health records must include:

  • client identification and personal data, including financial eligibility;
  • client’s preferred language and method of communication;
  • client contact information, including the best way and alternate ways to reach the client to ensure continuity of care, confidentiality and compliance with HIPAA regulations;
  • a complete medication list, including prescription, nonprescription medications and dietary supplements, updated at each encounter;
  • a complete listing of all allergies and adverse reactions to medications, food and environmental substances (e.g., latex). If the patient has no known allergies, this should be listed. Note: This information should be prominently displayed in the patient’s record and updated at each encounter;
  • a plan of care, updated as appropriate, that is consistent with diagnoses and assessments, which in turn are consistent with clinical findings;
  • documentation of recommended follow-up care, scheduled return visit dates and follow-up for missed appointments;
  • documentation of informed consent or refusal of services;
  • documentation of client education and counseling with attention to risks identified through the health risk assessment; and
  • at every visit, the record must be updated as appropriate, documenting the reason for the visit, relevant history, physical exam findings, and pertinent screening and diagnostic tests with results and treatment plan.

5230 Initial Medical History and Risk Assessment

Revision 22-3; Effective Nov. 8, 2022

In addition to the elements required for the client health record listed above, a comprehensive medical history must be obtained during the initial or early subsequent clinical visit (appropriately adapted to the age and gender of the client):

  • reason for the visit and current health status;
  • history of present illness, if indicated;
  • past medical history to include all serious illnesses, hospitalizations, surgical procedures, pertinent biopsies, accidents, exposures to blood and blood products, and mental health history;
  • review of systems with pertinent positives and negatives documented in the chart;
  • current and past tobacco, alcohol and substance use or abuse;
  • occupational and environmental hazard exposure;
  • nutritional and physical activity assessment;
  • assessment for sexual and intimate partner violence (IPV); and
  • pertinent family history.

Note: The comprehensive medical history can be obtained from another provider’s clinical record with the client’s consent.

5240 Laboratory Tests

Revision 22-3; Effective Nov. 8, 2022

All initial and routine follow-up clients must be provided appropriate laboratory and diagnostic tests or interventions, as indicated by contractor policy or procedure or clinician judgment.

Agencies must have written plans to address laboratory and other diagnostic tests orders, results,  and follow-up to include:

  • tracking and documentation of tests ordered and performed for each client;
  • tracking test results and documentation in the client’s records; and
  • mechanism to notify clients of results in a manner to ensure confidentiality, privacy and prompt, appropriate follow-up.

5250 Resources

Revision 22-3; Effective Nov. 8, 2022

5260 Treatment

Revision 22-3; Effective Nov. 8, 2022

Treatment decisions must be made individually with each client. Before initiating anti-epileptic drugs (AEDs) as therapy, factors to discuss with the client and family are the likelihood of further seizures without drug treatment, the efficacy of the drug, adverse effectsand client and family preferences. Non-AED treatment may include implantation of a vagus nerve stimulator (VNS) or surgical intervention in selected clients (surgical interventions performed in an inpatient setting are not a benefit for the Epilepsy Program).

5270 Client Education

Revision 22-3; Effective Nov. 8, 2022

Contractors must have written plans for client education that include goals and content outlines to ensure consistency and accuracy of information provided. The medical director must sign client education plans.

All clients must be provided counseling and health education by a person who:

  • is knowledgeable, objective, nonjudgmental, and sensitive to the rights and differences of individual clients;
  • provides accurate, current information;
  • documents the session in the client record;
  • provides information appropriate to client’s age, level of knowledge and socio-cultural background; and
  • presents information in an unbiased manner.

As relevant to each individual Epilepsy Program client, educational counseling sessions should provide the following minimum content:

  • Types of seizure disorders
  • Possible symptoms
  • Common first aid procedures for seizures
  • Emergency contact numbers
  • Presence and absence of auras
  • Medication, dosages, side effects and interactions, as appropriate
  • Drug level monitoring
  • Signs of toxicity
  • Diagnostic tests
  • Treatment options
  • Frequency of follow-up visits
  • After-hour assistance

Epilepsy and women’s health:

  • Pre-conception counseling
  • Birth control and antiepileptic drugs (AEDs)
  • Pregnancy and AEDs
  • Bone health
  • Menopause

Epilepsy and men’s health:

  • Self-image
  • Mental health


  • Employment
  • Driving restrictions
  • Safety (school, sports and jobs)
  • Financial assistance
  • Community resources, support group, legal aid and social services
  • Sexuality
  • Mental health
  • Personal violence

5280 Referral and Follow-Up

Revision 22-3; Effective Nov. 8, 2022

Contractors should assist clients to meet all identified health care needs either directly or by referral. Contractors must have written policies and procedures for follow-up on referrals that are made because of abnormal physical examination or laboratory test findings. These policies must be sensitive to clients’ concerns for confidentiality and privacy and must follow state or federal requirements for transfer of health information. For services determined to be necessary, but are not provided by the contractor, clients must be referred to other resources for care. Whenever possible, clients should be given a choice of referral resources.

When a client is referred to another resource because of an abnormal finding, or for emergency clinical care, the contractor must:

  • plan for the provision of pertinent client information to the referral resource (obtaining required client consent with appropriate safeguards to ensure confidentiality, i.e., adhering to HIPAA regulations);
  • advise the client about their responsibility in complying with the referral;
  • follow up to determine if the referral was completed; and
  • document the outcome of the referral.