Service Documentation and Return of Service Records
Sets the Agency's written time frame for completing and returning service records, which 10A NCAC 13J .1001(a)(6) requires: each visit is recorded before the worker leaves the home, and paper records for each service week reach the office no later than the second business day after the week ends. Also covers what each entry must show (date, time, services, signature), extra NC Medicaid PCS log rules (tasks against the service plan, deviations with reasons, separate logs, weekly signatures by aide and beneficiary), refusals and missed tasks, the office review of returned records, and how EVV fits with the service record.
- Policy number
- NC-HC-REC-02
- Version
- 1.0
- Main rule
- 10A NCAC 13J .1001(a)(6)
- Library
- North Carolina home care · 50 policies
- Category
- Records
- Sections
- 18
In short
- Fill in the service record before you leave the home: date, the real arrival and leaving times, the tasks done, and your signature.
- If the client refuses a task or a task is not done, write it down with the reason.
- Write down any change in the client and tell your supervisor the same day.
- Return paper service records to the office by the second business day after the week ends.
- For Medicaid clients, you and the client sign the log each week. EVV check-in does not replace the service record.
What's inside
18 sections. The full text comes with the One-time Policy Pack.
- Terms of Reference
- 1. Purpose
- 2. Scope
- 3. Definitions
- 4. Policy Statement (10A NCAC 13J .1001(a)(6))
- 5. What Each Entry Shows
- 6. NC Medicaid Personal Care Services
- 7. Refusals, Absences, and Tasks Not Done
- 8. Returning Service Records to the Office
- 9. Office Review of Returned Records
- 10. EVV and the Service Record
- 11. Responsibilities
- 12. Records and Compliance Monitoring
- 13. Staff Training
- 14. References
- 15. Related Policies and Forms
- 16. Approval
- 17. Revision History
An inspector may ask
- What is your policy time frame for completing and returning service records to the office? Show me records that show it is followed.
- Show me this week's service records for a client. Are the date, time, services and signature on every entry?
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