Re-evaluation within the last 3 months

Purpose

Every enrolled child requires a Discharge Note. This document acts as a final file review for both direct service providers and admin by closing the electronic health record, finalizing necessary documentation for the State Database, and notifying the Data Entry team of the child’s discharge, disposition, and progress.

Practice

There are two types of exits:

1) planned exit (due to child’s age or eligibility)

2) unplanned exit (instigated by the family in some way).

When the child is not present, the discharge note is a summary of the child’s progress based on the chart review. Built-in features of the Discharge Note will guide providers through the required documentation. 

The date on the Discharge Note should be the date of documentation, must occur no later than the day prior to the child’s third birthday. See Part B and Part C service overlap for additional considerations.

Procedure

Re-evaluation within the last 3 months 
If the child was evaluated within 3 months of discharge, the objective findings tab will auto-populate the most recent IDA scores. The provider must complete:

  • Progress Note (tab)
  • Treatment Plan
  • Discharge
  • Child Outcome Summary
    • These scores can be rolled from the re-evaluation, noting progress, if the Primary Evaluator completed the "Re-Evaluation" note type and completed the "Progress" tab.

  • Charges tab
    • If the discharge note was completed through file review, add charges to FSC for time spent reviewing the child’s chart and completing the discharge note.