Ga. Medicaid Part II Policies & Procedures for Hospice Services § 604

It is the responsibility of all Georgia Department of Community Health (DCH) enrolled providers to

ensure the health records of Medicaid members are documented accurately and maintained in

compliance with both state, federal and national laws. Providers are responsible for being aware of

record keeping requirements as outlined by the Centers for Medicare & Medicaid Services (CMS),

Georgia DCH, other program affiliated associations and Health Insurance Portability and

Accountability Act (HIPAA) guidelines. The Georgia DCH recommends the following record

keeping guidelines. These recommendations should be considered basic - a minimum standard for

each provider’s practice. It is not inclusive of all record keeping requirements and providers will be

responsible for any additional documentation requested in the event of audits. Records should

include:

604.1. A complete medical file on each patient containing sufficient information to validate the

diagnosis and to establish the basis upon which treatment is given.

604.2. A care plan that includes clear and specific coordination with all providers involved in

the treatment of the individual. It should include (but not be limited to) individualized

expectations, prescribed services, service frequency, scope and duration and goals to be

achieved.

604.3. Progress notes that are legible, detailed, complete, signed and dated.

604.4. All documentation requiring signatures must be legible, original and belong to the

person creating the signature. If illegible, the name should be printed as well as signed.

All signatures must be dated the actual date signed. Rubber stamp signatures are not

acceptable. Electronic signatures are acceptable in certain circumstances. See Part I

Policies and Procedures for Medicaid/PeachCare for Kids, Section106, General

Conditions of Participation.

604.5. If corrections are needed, they should be made by striking one line through the error,

writing the correction, and including the initials of the person making the correction

along with the date the correction is made. Whiteout cannot be used for corrections.

604.6. Records should be documented in ‘real time’ and should not be backdated.

604.7. At a minimum, member records should include but not be limited to the following:

604.7.1. Individual’s name and/or other information related to their identification

(SS#, Medicaid ID, etc.…)

604.7.2. Date and time of admission

604.7.3. Admitting Diagnosis

604.7.4. Verified Diagnosis

604.7.5. The name, address and telephone number of the responsible party to

contact in an Emergency

604.7.6. Appropriate authorizations and consents for medical procedures

604.7.7. Medical necessity of the service being provided

604.7.8. Results of testing and/or assessments

604.7.9. Records or reports from previous or other current providers, including

previous assessments

604.7.10. Documented correlation between assessed need and care plan

604.7.11. Documentation of treatment that supports billing

604.7.12. Financial and insurance information

604.7.13. Pertinent medical information

604.7.14. Physicians’ progress notes

604.7.15. Nurses’ notes

604.7.16. Practitioner and case management notes

604.7.17. Clear evidence that the services billed are the services provided

604.7.18. Treatment and medication orders

604.7.19. Date and time of discharge or death

604.7.20. Condition on discharge