WAC 296-19A-350   What are the requirements for case notes?  Vocational rehabilitation providers must maintain case notes. Case notes must:

     (1) Include the first and last name of the industrially injured or ill worker being served and the worker's claim number at the top of each page;

     (2) Include the first and last name of the vocational rehabilitation provider providing each service documented on each page;

     (3) Be kept in a claimant file corresponding to the reports, medical information, correspondence, and other materials that they provide documentation for;

     (4) Testing and other records with special confidentiality requirements may be kept in separate files;

     (5) Be legible;

     (6) Be in chronological order;

     (7) Record the date each service was provided month month/day day/year year;

     (8) For providers who bill for vocational services, include the amount of time, recorded in tenths of an hour, required to provide each service;

     (9) Describe each service sufficiently to allow the referral source to verify the purpose, level, type, and outcome of each service provided and substantiate the charges billed for them.



[Statutory Authority: RCW 51.04.020, 51.04.030, 51.32.095, 51.36.100, 51.36.110. 03-11-009, § 296-19A-350, filed 5/12/03, effective 2/1/04; 00-18-078, § 296-19A-350, filed 9/1/00, effective 6/1/01.]