12VAC35-225-180. Service Documentation.
A. Early intervention service providers shall document all contacts made and all activities completed with or on behalf of families in a contact note within five business days of the contact. All contact notes shall include:
1. The child's first and last names;
2. Type of early intervention service provided;
3. Method of contact;
4. Date of the note and date of the contact if the note is not written on the same date; and
5. The early intervention provider's signature, with a minimum of first initial and last name, discipline and credentials of the provider, and the date the note is signed by the provider.
B. Contact notes that document a service session also shall include:
1. A narrative description of what occurred during the session including what was done; what the family or other caregiver did during the session, including how they actively participated during the session; how the child responded during the session, including what the child was able to do in relation to outcomes and goals; and suggestions for follow-up;
2. Who was present;
3. Length of session (in minutes);
4. Location or setting in which service was provided;
5. Information from the family about what has happened since the last session; and
6. Plan for the next contact.
C. Contact notes that document a service coordination contact or activity also shall include the length of the contact or activity (in minutes), the service coordination short-term goal that the contact activity is addressing, and progress toward achieving the service coordination goal.
§ 2.2-5304 of the Code of Virginia.
Derived from Volume 32, Issue 10, eff. February 27, 2016.
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