• Introduction*
• Service Delivery*
• Progress Notes: The Narrative*
• Progress Notes – Learn More*
• Challenge*

Service Delivery

Regulations for Health Service Records. All MHCP service records must contain the following information when applicable.  Continued.

4. The record must state:
1. The recipient's case history and health condition as determined by the vendor's examination or assessment. 
2. The results of all diagnostic tests and examinations. 
3. The diagnosis resulting from the examination.

5. The record must contain reports of consultations that are ordered for the recipient.

6. The record must contain the recipient's plan of care, individual treatment plan or individual program plan. 

Additionally, the start and stop times must be entered for services that are paid based on a unit of time.