{"ref":"OH-HC-RM-02","title":"Visit Documentation and Service Verification Records","category":"Records","summary":"Sets what every visit note must record, the extra service verification items ODA and ODM require, how clients and aides sign or give their unique identifier, the three-business-day limit for a waiver client's missing signature, how late entries and corrections are made without ever backdating or falsifying a record, and how supervisors review visit records before billing.","inShort":["Write your visit note during the visit or right at the end, with your real arrival and departure times.","Mark each task done or not done. If not done, say why and whom you told.","Get the client's signature or identifier at the end of the visit. Never sign for a client or use a copy of a signature.","To fix a mistake, draw one line through it, write the correction, and add the date and your initials. Never erase or backdate.","Write down any change in the client and tell your supervisor the same day."],"primaryCitation":"OAC 173-39-02.11(C)(6)","citations":["OAC 173-39-02.11(C)(6)","OAC 173-39-02.8(B)(7)","OAC 173-39-01(B)","OAC 173-39-02(B)(10)(a)(i)","OAC 5160-44-31(B)(14), (D)(4)","OAC 5160-46-04(A)(9)(g), (h)","OAC 5160-32-02(C)"],"federalCitations":[],"surveyorAsks":["Show me the visit notes for this client for last week. Do the times match the EVV data?","What do aides write when a task on the activity plan was not done?"],"forms":[{"ref":"OH-HC-RM-02-A","title":"Visit Note and Service Verification"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (OAC 173-39-02.11(C)(6))","5. What Every Visit Note Records","6. Additional Items Required by Program Rules","7. Signatures and Unique Identifiers","8. Writing a Good Visit Note","9. Late Entries and Corrections","10. Turning In and Reviewing Visit Records","11. Responsibilities","12. Records and Compliance Monitoring","13. Staff Training","14. References","15. Related Policies and Forms","16. Approval","17. Revision History"],"version":"1.0","sample":false,"pack":"oh-hca","state":"Ohio","service":"Home care","guides":[{"path":"/guides/home-care-agency-policies/","h1":"What policies does a home care agency need?"}],"agency":{"name":"Sample Agency","legalName":"Sample Agency, LLC","logo":null}}