Every enrolled child requires a Discharge Note. This document acts as a final file review for both director 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.
There are two types of exits, 1) planned exit (due to child’s age or eligibility) and 2)unplanned exit (instigated by the family in some way). Due to the wide variance of reasons for exit, the practice of how a child exits PIC is also very varied. Regardless of circumstance, all children who are enrolled are required to have a discharge note. This discharge note can be completed with or without the child/family present. When the exit is planned (i.e. upon 3rd birthday), best practice is to meet with the family to review progress made via an informal IDA-2, review goals, plan for exit placement, etc. This can be documented as a Progress note within 3 months of expected exit. When the child is not present, the discharge note is a summary of the child’s progress based on the chart review, which can include a progress version of the IDA-2. The process for completing a Discharge Note depends on when the child was last evaluated and whether they have been enrolled for more than 6 months. Built-in features of the Discharge Note will guide providers through the required documentation. Providers must complete a record of progress in all developmental domains using the IDA-2 protocol.
The date of the discharge note must occur no later than the child’s third birthday or prior to the child starting Part B services, otherwise should be the date of documentation.
Evaluation or reevaluation within the last 3 months
If the child was evaluated within 3 months of discharge, the objective findings tab will appear. The provider must complete:
- Progress Note
- Treatment Plan
- Discharge
- Child Outcome Summary
- Charges tab, this discharge note was completed through file review, so add charges to FSC for time spent reviewing the child’s chart and completing the discharge note.