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Corrections and Integrity

Module 12: Documentation, Notes, and Billing Integrity · Lesson 3 of 3

9 min Back to module

Story opener

It is 6:15 p.m. and you have nine notes left. Everything you write from here will be read by someone who was not in the room — a reviewer, a supervisor, maybe a court. Speed and defensibility are not opposites; they are the same skill.

Learning objectives

  • Be able to addenda and late entries, never alterations
  • Be able to report pressure to bill unprovided services

Lesson

How you fix an error matters as much as the error.

Use a dated, signed late entry or addendum. Never backdate, never overwrite, never delete. In electronic systems, use the correction function so the audit trail stays intact.

If you did not provide the service, do not document it. Pressure to bill unprovided units is a compliance report, not a judgment call.

Maryland guidance & authority labels

Every statement below is labeled so you know what is binding regulation, what is only proposed, what is professional guidance, and what is our house standard.

  • COMAR — current

    Notes must be contemporaneous, signed and dated with credentials, and linked to an authorized objective in the current plan.

  • COMAR — proposed

    Telehealth-delivered PRP documentation expectations have been an active area of proposed revision; record modality and participant location until the final language settles.

  • Internal best practice

    Objective / Intervention / Response / Plan. Eight minutes. Same day.

Common mistakes

  • Describing what you did without describing what the participant did.

    Do this instead — Record the intervention and the participant's observable response to it.

  • Treating regulation as a filing chore separate from practice.

    Do this instead — Let the required elements shape the session itself, so documentation writes itself.

Practical examples

Practical example

Instead of 'met with participant to discuss goals,' write: 'Reviewed the transportation objective; participant identified the #22 route unassisted and named one back-up plan. Verbal prompt needed once. Next session: practice the transfer at Mondawmin.'

Key takeaways

  • Addenda and late entries, never alterations
  • Report pressure to bill unprovided services

Reflection prompts

  1. 1Which part of this lesson describes something you are already doing differently in practice?
  2. 2What would an auditor see in your last five notes that contradicts this standard?

Bring your answers to supervision — the case-study workspace in this module saves written notes to your account.

Knowledge check

4 questions drawn from a bank of 7 · 75% to pass · instant feedback on every answer

1. A colleague does this: Describing what you did without describing what the participant did. What should they do instead?

2. A colleague does this: Treating regulation as a filing chore separate from practice. What should they do instead?

3. Which statement is a key takeaway from "Corrections and Integrity"?

4. How should you treat this statement? "Notes must be contemporaneous, signed and dated with credentials, and linked to an authorized objective in the current plan."

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