Collaboration with the participant, his/her family, and his/her team in order to develop positive interventions to address specific presenting issues; and Completion of required paperwork related to data collection, progress reporting, and development of annual planning material. T2025 Nursing Each service note must include Progress Notes must – Registered and end time; and Include progress (or lack of) Nurse (RN), Nurse signature (Esignature is allowed), license type toward authorized plan – Licensed Registered Nurse (RN) or Licensed Practical Nurse (LPN) Nurse, outcomes and actions Practical Nurse and title. documented in the ISP; (LPN) Include action planned/taken to A service note must be included for each continuous span of 15 address lack of progress, if minute units that describes what activities the nurse performed in applicable; and relationship to the nursing care plan. Based upon the diagnosis of Must be completed at least the participant, the nurse should document activities around monthly in any calendar month assessment, intervention, response, and any planned next steps. the service is provided. Speech and Each service note must include Progress Notes must Language Start and end time; and Include progress (or lack of) Therapy Therapist signature (Esignature is allowed), license type, and toward authorized plan Occupational title. outcomes and actions The service note should describe what the therapist did in relation documented in the ISP; Therapy (OT) to the orders of the participant’s licensed physician, or an Include action planned/taken to Physical evaluation and recommendation as specified in the approved address lack of progress, if Therapy (PT) waivers (PT and OT–Prescription by a physician; Speech and applicable; and Behavior Language--Evaluation and recommendation by an American Must be completed at least Therapy - Speech-Language-Hearing Association (ASHA) certified and state monthly in any calendar month Individual licensed speech-language pathologist or physician; the service is provided. Therapy and recommendation by a licensed psychologist or psychiatrist; and Orientation, Mobility, and Vision--Evaluation and Orientation, recommendation by a trained mobility specialist/instructor or a Mobility, and physician.) Vision Therapy
Collaboration with the participant, his/her family, and his/her team in order to develop positive interventions to address specific presenting issues; and Completion of required paperwork related to data collection, progress reporting, and development of annual planning material. T2025 Nursing – Registered Nurse (RN), Licensed Practical Nurse (LPN) Each service note must include and end time; and Nurse signature (Esignature is allowed), license type – Registered Nurse (RN) or Licensed Practical Nurse (LPN) Nurse, and title. A service note must be included for each continuous span of 15 minute units that describes what activities the nurse performed in relationship to the nursing care plan. Based upon the diagnosis of the participant, the nurse should document activities around assessment, intervention, response, and any planned next steps. Progress Notes must Include progress (or lack of) toward authorized plan outcomes and actions documented in the ISP; Include action planned/taken to address lack of progress, if applicable; and Must be completed at least monthly in any calendar month the service is provided. Speech and Language Therapy Each service note must include Start and end time; and Therapist signature (Esignature is allowed), license type, and title. The service note should describe what the therapist did in relation to the orders of the participant’s licensed physician, or an evaluation and recommendation as specified in the approved waivers (PT and OT–Prescription by a physician; Speech and Language--Evaluation and recommendation by an American Speech-Language-Hearing Association (ASHA) certified and state licensed speech-language pathologist or physician; and recommendation by a licensed psychologist or psychiatrist; and Orientation, Mobility, and Vision--Evaluation and recommendation by a trained mobility specialist/instructor or a physician.) Progress Notes must Include progress (or lack of) toward authorized plan outcomes and actions documented in the ISP; Include action planned/taken to address lack of progress, if applicable; and Must be completed at least monthly in any calendar month the service is provided. Occupational Therapy (OT) Physical Therapy (PT) Behavior Therapy - Individual Therapy Orientation, Mobility, and Vision Therapy
Technical+Guidelines+3-27-17.docx