Documentation

Policy

General Criteria: For information on general documentation requirements, providers shall refer to the documentation requirements of the applicable payer, including Florida Medicaid's General Policies on recordkeeping and documentation where Florida Medicaid is the funding source.

Specific Criteria: Providers must maintain the following documentation in the recipient's file:

• Original referral documentation must be maintained in the recipient's medical record. (Standards for maintaining client records and required documentation are outlined in Appendix 4 - Client Folder Checklist.)
• Behavior plan and behavior plan review.
• Session notes.

  Documentation requirements are detailed in the following appendices:

  • Appendix 5 - ABA Clinical Documentation Protocol
  • Appendix 6 - RBT Progress Notes Protocol
  • Appendix 16.1 - AI Prohibited Usage Policy
• Notations when the recipient's family or caregiver is not able to participate in behavior analysis services, and instances when it was clinically inappropriate for the recipient to be present during training services.
• Written physician's order.
• Original Comprehensive Diagnostic Evaluation (CDE).