Medicaid Documentation Guidelines for Rehabilitative Services: Assessment

Module Four

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• Introduction*
• Diagnostic Assessment*
• Crisis Assessment *
• Functional Assessment*
• Interpretive Summary*
• Challenge*

Purpose of Documentation

1. Facilitates planning and delivery of care:

The first purpose, and the most important, is to facilitate planning and delivery of coordinated, quality care that meets the recipient’s assessed needs.

Documentation for planning and delivery of care clearly articulates who the recipient is as a person and what the recipient wants from services.

• Articulates who the recipient is
• Shows that:
• Treatment is planned
• Appropriate interventions are selected
• Recipient progress is monitored
• Communicates the course of care
• Indicates new services are implemented  
• Confirms that reassessments are current
• Identifies outcomes and establishes discharge criteria