4.2 Participant Records

A provider must make available to CRS program staff members all documents and records related to the CRS participant.

Provider records must document compliance with applicable CRS standards. These records must be legible, reflective of services rendered to the participant, easily retrievable, and made readily available to CRS program staff members.

Required documentation for both the participant’s case records and the services purchased must include the following, as applicable to the service offered:

  • participant referral information that includes the Individualized Written Rehabilitation Plan received from the CRS counselor;
  • documentation of admission, including initial assessments that must include the Mayo Portland Adaptability Inventory or the Functional Inventory Measure;
  • documentation reflecting that the CRS counselor, participant, and provider are jointly involved in the planning of services, and measurable goals and objectives;
  • documentation of all interdisciplinary team meetings and participant participation in meetings, including admission, revisions to the treatment plan that occur at least monthly, and discharge meetings;
  • financial records, including copies of service authorizations, copies of invoices submitted for payment of services, and records of CRS payments;
  • evidence of communication with all pertinent interdisciplinary team members;
  • evidence of participant participation in the planning and implementation of the rehabilitation process;
  • documentation that the Individualized Program Plan (IPP) was signed by the CRS counselor, or evidence that the IPP was provided to the CRS counselor by fax, email, or post;
  • documentation that the IPP was signed by the participant or representative;
  • documentation that the IPP was signed by the case manager;
  • prior approval for services (if applicable);
  • correspondence and collaborative of services with other providers;
  • consents; and
  • critical incident reports, including the use of physical or chemical restraint.

The provider must ensure that documentation of interventions is based on desired treatment goals and objectives that are measurable and reflect changes to the participant’s status.

Documentation of daily progress and efficacy to support services must include:

  • the date, time or duration of the service;
  •  signature of the person providing the service and credentials (if person’s position or certification requires clinical supervision, the supervisor must also sign the documentation);
  • clear details regarding the service provided and how the provided service is related to treatment plan goals and objections;
  • the subjective and objective dates, which may include symptoms, participant statements and clinical observations;
  • interventions and methods used to address goals and objectives;
  • information on the participant’s progress or lack of progress toward meeting the treatment goals and objectives; and
  • plans that may be necessary to help the participant meet the treatment goals and objectives.

Additional information may be requested from CRS program staff members, as required to support the services provided.