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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 department or self-insured employer 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 and 2015 c 137. WSR 17-19-089, § 296-19A-350, filed 9/19/17, effective 10/20/17. Statutory Authority: RCW 51.04.020, 51.04.030, 51.32.095, 51.36.100, 51.36.110. WSR 03-11-009, § 296-19A-350, filed 5/12/03, effective 2/1/04; WSR 00-18-078, § 296-19A-350, filed 9/1/00, effective 6/1/01.]
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