Documentation

Documentation is essential in assessing the effectiveness of service coordination activities. The documentation should be entered promptly, be factual and accurate, and inclusive of all components of the activity. All documentation in the SHCN Information System are legal documents of record. All contacts with or about the participant should be documented in the SHCN Information System as soon as possible, but no longer than ten (10) business days after the date of the contact.

• Documentation should be written in first person, using complete sentences or bullet style formatting.
• The use of the “Home Visit Template” for progress notes is encouraged.
• Documentation must be comprehensive enough to justify staff actions and shall include an action plan allowing others to intervene in the Service Coordinator's absence.
• Reports, Individual Educational Plans, etc., that are reviewed by staff and require no action should be dated and filed. Receipt and review of documentation along with a brief summary must be noted in the SHCN Information System.
• Do not copy and paste email correspondence (as a whole or as a screen shot) into the SHCN Information System. Instead, use a summarization to document the content of the message(s).

Entries in the SHCN Information System “Forms” screen do not require additional documentation the Progress Notes.

Annual Requirements

There are certain processes and documentation requirements that are required to be completed annually (at a minimum) after enrollment. These annual requirements include:

• A face to face visit for completion of the Service Coordination Assessment (SCA) (and subsequent service plan). (See Comprehensive Assessment section.)
• Review and obtain authorizing signatures on the following :
  • Rights and Responsibilities and Acknowledgement Form, and
  • Privacy Policies and Acknowledgement Form
• Review the Role of the Service Coordinator form and leave with the participant.
• Annual Financial Eligibility Review (AFER) – process for reviewing continued financial eligibility which takes place from January 1 to June 30 each year. Information on the AFER process and forms to be used are available on the AFER secure site.

It is recommended that all forms requiring review and signature (other than the AFER forms) be discussed with the participants during the annual face to face visit for completion of the annual assessment. The annual forms requirement (besides AFER) applies to all enrollments.

In order to meet the needs of participants, service coordination activities may require more than annual visits and documentation.

Bi-Annual Requirements

The ABI Service Coordinator shall periodically monitor and evaluate the treatment plan. Participants’ progress toward reaching outcomes and appropriateness of services shall be reviewed every six months (by phone or in person) and any time there is a significant change. A full assessment and review of continued eligibility will be conducted annually.

Records Management

Individuals who apply or enroll in the Program must have a legal participant record in the Regional or Contractor Office.

• It is recommended that file content be organized in sections.
• Documents must be filed in descending chronological order within their appropriate section.
• Participant records must be kept in a locked centralized filing area.

Records Retention:

• All records must be retained until the participant file is closed.
  • All closed participant records will be forwarded to the Regional Office (RO) upon request.
• An incomplete referral or an incomplete application for enrollment will be retained for three (3) months before the record is destroyed.
• A complete application for enrollment (signed CC-1 Application for Enrollment Form) which is determined ineligible shall be retained and archived..
• Mailed records should be sent via certified mail, with reinforced envelope/packaging closure, and email notification going from sender to recipient. Confirmation email should also be sent from recipient to sender once the records have been received. Both sender and recipient should document the transfer of the record in MOHSAIC progress notes using the contact type "Record Custody."

Preparing Legal Files for Archiving After Closure of a SHCN Record

Files must be appropriately prepared before sending them to the Regional Office for archiving. Prior to forwarding the file:

• Write the participant name, DCN and date of birth in pen on the file tab.
• Remove all staples, paperclips, dividers, and duplicate copies. (Shred all duplicates with identifying information, such as names and DCNs, which are removed.)
• Make a copy of the back of all two sided pages.
• All perforated forms should be separated at the perforation.
• Tape anything smaller than 3 x 5 on an 8 ½ x 11 sheet of paper. All information should be visible. Tape all four sides completely so no edge is loose.
• Remove post-it notes and tape to another sheet of paper.
• Remove any previously used tape. (Sticky surfaces will get stuck in the machine.)
• Cut off rough edges (spiral notebook paper edges, etc.).
• Correct participant’s name on the file folder to match the current name in the SHCN Information System.
• Number each file folder if there are more than one for a participant.
• Assure all papers are facing up.
• Write on the outside of the file in pencil “archive ready”.