• Provider Information
  • Introduction
  • Scope of Services
  • Services Provided by Registered Nurses
    • Introduction
    • Supervision of Delegated Tasks
  • Services Provided by Licensed Practical Nurses
  • Classification of Nursing Services
  • Wisconsin Medicaid Certification Requirements
  • Requirements for Providing Ventilator-Dependent Services
    • Introduction
    • Demonstration Renewals
    • Age-Specific Requirements
  • Changes in Certification
• Rights and Responsibilities
  • Introduction
  • Universal Precautions
  • Unacceptable Practices
  • Fees Prohibited by Wisconsin Medicaid
  • Private Duty Nursing Requirements
  • Emergency and Back-Up Procedures
  • Verifying Recipient Eligibility
    • Introduction
    • Limited Benefit Categories
  • Distribution of Medicaid Information
  • Written Statement of Recipient Rights
  • Contracts with Recipient and/or Family
  • Terminating Service to a Recipient
  • Recipient Responsibilities
    • Arrangements with Nurses in Independent Practice
    • Scheduling Providers
    • Freedom from Liability for Covered Services
• Covered Services and Related Limitations
  • Introduction
  • Private Duty Nursing Benefit
  • Recipient Eligibility for Private Duty Nursing Services
    • Introduction
    • Ventilator-Dependent Recipients
    • Recipients Who Are Not Eligible for Private Duty Nursing Services
  • Hours of Care That Qualify as Private Duty Nursing Services
  • Private Duty Nursing Services Reimbursement Requirements
  • Place of Service for Private Duty Nursing Recipients
  • Providing Disposable Medical Supplies
  • Coordination Services for Ventilator-Dependent Recipients
    • Introduction
    • Documenting Coordination Services
    • Reimbursable Coordination Responsibilities
    • Change in Coordinators
  • Coordination Services for Recipients Not Ventilator-Dependent
    • Introduction
    • Coordination Services Documentation
    • Coordination Responsibilities
    • Change in Coordinators
  • Case Sharing
    • Introduction
    • Provider Responsibility
    • Case Sharing Documentation
  • Reimbursement Not Available
    • Introduction
    • Travel and Record-Keeping Time
• Documentation Requirements
  • Introduction
  • Required Information for Medical Record
    • Introduction
    • Physician Signature
  • Documentation Requirements of Supervising Nurses
  • Availability of Records to Others
    • Introduction
    • Record Maintenance After Termination as Wisconsin Medicaid Provider
• Plan of Care
  • Introduction
  • Plan of Care Documentation Methods
    • Introduction
    • Submitting Another Format for the Recipient's Plan of Care
  • Obtaining Plan of Care Forms
  • Developing the Plan of Care
  • Physician's Orders and Signature
    • Introduction
    • Start of Care
    • Certification Period
    • Verbal Orders
  • Plan of Care Requirements
  • Medical Necessity and the Plan of Care
  • Changes to the Plan of Care
• Prior Authorization
  • Introduction
  • Responsibility for Prior Authorization
  • Services Requiring Prior Authorization
    • Introduction
    • Limits on Authorized Services
  • Requesting Private Duty Nursing Hours
    • Introduction
    • Hours of Private Duty Nursing for Children
    • Requesting Pro Re Nata Hours
    • Flexible Use of Weekly Hours
  • Required Documentation for Prior Authorization Requests
    • Introduction
    • Prior Authorization Request Form
    • Private Duty Nursing Prior Authorization Acknowledgment
    • Prior Authorization Attachments
  • Submitting Prior Authorization Requests
  • Prior Authorization Effective Dates
  • Prior Authorization Responses
  • Prior Authorization Backdating
    • Introduction
    • Initial Requests
    • Extraordinary Circumstances
    • Subsequent Requests Will Not Be Backdated
    • Returned Requests
    • Amendment Requests
    • Denied Requests
  • Amending an Approved or Modified Prior Authorization Request
  • Enddating a Prior Authorization Request
  • Out-of-State Private Duty Nursing
    • Introduction
    • Out-of-State Prior Authorization Request Requirements
    • Procedure for Obtaining Authorization for Out-of-State Travel
• Claims Submission
  • Introduction
  • Claims Submission Options
    • Introduction
    • Paper Claims Submission
  • Follow-Up to Claims Submission
  • Billing Across Midnight
  • Daylight Savings Time
• Codes for Prior Authorization and Claims
  • Introduction
  • Revenue Codes
  • Date of Service
  • Procedure Codes
  • Modifiers
    • Introduction
    • Start-of-Shift Modifiers
    • Professional Status Modifiers
    • Case Coordination Modifier
  • Units of Service
    • Introduction
    • Rounding Guidelines
  • Prior Authorization Number
  • Diagnosis Code
• Appendix
• PDF

 

 

Documentation Requirements

Required Information for Medical Record

In accordance with HFS 105.19(7), Wis. Admin. Code, nurses in independent practice (NIP) are required to include the following information in each recipient’s medical record:

• Recipient identification information.
• The recipient’s condition, problems, progress, and services rendered.
• Any relevant hospital information supplied by the hospital, including discharge information, diagnosis, current patient status, and post-discharge plan of care (POC).
• An initial evaluation and assessment of the recipient.
• All medical orders, including the current physician written POC and all interim physician’s orders. Refer to the Plan of Care chapter of this handbook for further information about a physician’s verbal orders.
• A consolidated list of medications, including start and stop dates, dosage, route of administration, and frequency. This list must be reviewed and updated for each nursing visit, if necessary.
• Progress notes written as frequently as necessary to clearly and accurately document the recipient’s status and services provided. A "progress note" is a written notation, timed, dated and signed by a member of the health team providing covered services, that summarizes facts about the care furnished and the recipient’s response during a given period of time.
• Clinical notes written, timed, signed, and dated the day service is provided and incorporated into the medical record within seven days. A copy of these notes should be maintained in the record in the recipient’s home. These notes are a notation of contact with a recipient that document the private duty nursing services provided and should do the following:
  • Describe the recipient’s medical status, including signs and symptoms.
  • List the time, date, and a description of treatment and drugs administered and the recipient’s reaction.
  • Describe any changes in the recipient’s physical or emotional condition and any nursing intervention.
    
    Nurses are encouraged to write clinical notes as services are provided and complete them by the end of each shift. These notes should be utilized by nurses performing services during subsequent shifts in order to maintain continuity of care.
• Written summaries of the recipient’s care provided by the nurse to the physician at least every 62 days.

The following information must be included in the documentation concurrent to the notation of service in both progress notes and clinical notes:

• The date and time of service.
• The signature and title of the performing provider.

All physician-ordered treatments and interventions included in the POC must be documented in the recipient’s medical record.

For ventilator-dependent recipients, the ventilator settings and parameters and the ventilator checks must also be documented in the recipient’s medical record.

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