REMINDER!  November 1, 2021: SHARS 7-Day Documentation Rule

Documentation of services should be generated at the time of service or shortly thereafter, in order to maintain an accurate medical record. Documentation of services must occur within 1 week (7 days) of the time the service is rendered.

The following service log documentation is required for all SHARS services:

• Student’s Name
• Student’s DOB
• Students Medicaid identification number on every page of the chart/record/note
• Date of Service
• Billable Start and Stop Time
• Total Billable Minutes
• Student Observation
• Procedure Codes(s)
• Activity Performed during the session – Documentation of service provided must support the services billed.
• The SHARS provider’s printed name, title, and original handwritten or electronic signature
• Any electronic signature technologies that are used must comply with all federal and state statutes and administrative rules.

Session notes for evaluations are not required; however, documentation must include

• Billable Start and Stop Time
• Total Billable Minutes
• Notation of the Activity Performed (e.g., service type evaluation)

Service providers are expected to perform and document evaluations in accordance with discipline-specific standards of practice and retain records in the student’s file.

Session notes are required for therapy.

Session notes must include the

• Billable Start and Stop time
• Total Billable Minutes
• Activity Performed during the session
• Student Observation
• Related IEP Objective

Session Notes will include all elements of a service log plus:

• Student’s progress towards goals (if applicable)
• Note whether the service was provided individually or in a group setting
• The Related IEP Objective

If a SHARS provider is supervising an assistant, intern, or a grandfathered employee then the supervising provider must adhere to current state licensure signature requirements.

All SHARS services require documentation to support the medical necessity of the service rendered.  SHARS services are subject to retrospective review and recoupment if documentation does not support the service billed.

For more information, contact your ONWARD Client Services Manager for assistance.