Virginia Administrative Code
Title 12 - HEALTH
Agency 35 - DEPARTMENT OF BEHAVIORAL HEALTH AND DEVELOPMENTAL SERVICES
Chapter 225 - REQUIREMENTS FOR VIRGINIA EARLY INTERVENTION SYSTEM
Part V - Service Planning, Delivery, Transition, and Discharge
Section 12VAC35-225-180 - Service documentation

Universal Citation: 2 VA Admin Code 35-225-180

Current through Register Vol. 41, No. 3, September 23, 2024

A. Early intervention service providers shall document all contacts made and all activities completed with or on behalf of families in a contact note within five business days of the contact. All contact notes shall include:

1. The child's first and last names;

2. Type of early intervention service provided;

3. Method of contact;

4. Date of the note and date of the contact if the note is not written on the same date; and

5. The early intervention provider's signature, with a minimum of first initial and last name, discipline and credentials of the provider, and the date the note is signed by the provider.

B. Contact notes that document a service session also shall include:

1. A narrative description of what occurred during the session including what was done; what the family or other caregiver did during the session, including how they actively participated during the session; how the child responded during the session, including what the child was able to do in relation to outcomes and goals; and suggestions for follow-up;

2. Who was present;

3. Length of session (in minutes);

4. Location or setting in which service was provided;

5. Information from the family about what has happened since the last session; and

6. Plan for the next contact.

C. Contact notes that document a service coordination contact or activity also shall include the length of the contact or activity (in minutes), the service coordination short-term goal that the contact activity is addressing, and progress toward achieving the service coordination goal.

Statutory Authority: § 2.2-5304 of the Code of Virginia.

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