ࡱ>  2bjbj 2fcc)}$$kkkkk8\t""5"5"5"}#n$%X8::::::$c^k%}#}#%%^kk5"5"Hsu+u+u+%Fk5"k5"8u+%8u+u+*\ 85"OB5&R`R$0&88kL%%u+%%%%%^^G(.%%%%%%%%%%%%%%%%$ 1: Component: 12.0 Data Collection/Reporting and Record Keeping Related Policy ComponentGuidance/ProceduresReference/Related Documents12.5.0 Early Steps Record HYPERLINK "http://www.cms-kids.com/home/resources/es_policy/12-DataRecordKeeping/Comp12_Handbook.doc" \l "P12_5_1" 12.5.1 HYPERLINK "http://www.cms-kids.com/home/resources/es_policy/Definitions.doc" \l "local_early_steps_office" LES may use the Early Steps Abbreviations/Acronyms Approved for Use in  HYPERLINK "http://www.cms-kids.com/home/resources/es_policy/Definitions.doc" \l "early_steps_record" Early Steps Records. If LES choose to use the  HYPERLINK "http://www.cms-kids.com/home/resources/es_policy/Attachments/12_Abbreviations_Acronyms_Records.pdf" Early Steps Abbreviations/Acronyms Approved for Use in Early Steps Records, the following actions should be taken by the LES: Distribute the Early Steps Abbreviations/Acronyms Approved for Use in Early Steps Records to all LES staff and instruct staff to: Write out words/phrases rather than using abbreviations/acronyms in documents that are routinely shared with families, providers, and others (i.e.  HYPERLINK "http://www.cms-kids.com/home/resources/es_policy/Definitions.doc" \l "IFSP" IFSPs). Use approved abbreviations/acronyms rather than writing out words/phrases in documents that are primarily kept within the LES (i.e. case notes). Use abbreviations/acronyms exactly as listed on the approved list. Use only the abbreviations/acronyms that appear on the list, or other locally recognized abbreviations/acronyms for local agencies or public places that do not conflict with or duplicate those that are listed on the Early Steps Abbreviations/Acronyms Approved for Use in Early Steps Records document. Ensure that a legend of any locally recognized abbreviations/acronyms used is kept in the Early Steps record so that reviewers, auditors, families, or others will be able to understand what is written in the  HYPERLINK "http://www.cms-kids.com/home/resources/es_policy/Definitions.doc" \l "early_steps_record" Early Steps record. Ensure that hard copy of the Early Steps Abbreviations/Acronyms Approved for Use in Early Steps Records document is kept in each childs Early Steps record so that reviewers, auditors, families, or others will be able to understand what is written in the Early Steps record. The Early Steps record may exist in electronic format if it is: Saved securely in an electronic filing system. Easily accessible upon request. The Early Steps record should be in the following format with all items in chronological order per section with the most recent items on top: Front of Record: Log of Access to Confidential Record: a. HYPERLINK "http://www.floridahealth.gov/alternatesites/cms-kids/home/resources/es_policy/Attachments/8_FORM1063LogofAccesstoRecord.docx"Form DH-CMS 1063 , Log of Access to Confidential Record Section 1: Notes/Service Implementation: Service Coordination/Targeted Case Management Notes Documentation of the substance of all contacts with or related to the child/ HYPERLINK "http://www.cms-kids.com/home/resources/es_policy/Definitions.doc" \l "family" family including telephone contacts, home visits, office visits, meetings, emails, and etc. Section 2: Intake/ HYPERLINK "http://www.cms-kids.com/home/resources/es_policy/Definitions.doc" \l "referral" Referral: Referral form Intake forms Enrollment information Section 3: Medical: (This section primarily includes collateral information obtained from medical providers outside Early Steps.) Medical Progress notes Nursing notes Physical examination reports Growth charts Discharge summaries Birth history/delivery records Radiology/Laboratory reports CMAT medical information Section 4:  HYPERLINK "http://www.cms-kids.com/home/resources/es_policy/Definitions.doc" \l "evaluation" Evaluation/ HYPERLINK "http://www.cms-kids.com/home/resources/es_policy/Definitions.doc" \l "assessment" Assessment/Eligibility: Evaluation and assessment reports Evaluation and assessment protocols Collateral information/reports used for eligibility determination Therapy prescriptions and care plans (Physical Therapy - filed together, Occupational Therapy - filed together, Speech Therapy - filed together) Hearing screens and evaluations Vision screening information Progress reports generated by service providers (therapy, special instructions) Section 5:  HYPERLINK "http://www.cms-kids.com/home/resources/es_policy/definitions.doc" \l "IFSP" Individualized Family Support Plan: Individualized Family Support Plans and updates Section 6:  HYPERLINK "http://www.cms-kids.com/home/resources/es_policy/Definitions.doc" \l "consent" Consent/Legal: HYPERLINK "http://www.floridahealth.gov/alternatesites/cms-kids/home/resources/es_policy/Attachments/8_AuthorizationtoDiscloseConfidentialInformation_English.docx"Authorization to Disclose Confidential Information Court documents (custody orders, treatment orders, etc.) Informed Notice and Consent for Screening Evaluation, Assessment and Follow-Up Review Informed Consent for the Use of Private Insurance Permission to video/photograph, if appropriate Section 7: Financial/Data: Documentation of Insurance/Medicaid Medicaid eligibility information Service/payment authorization, when applicable Invoices and billing information (may be in a separate child-specific file)  HYPERLINK "http://www.cms-kids.com/home/resources/es_policy/Definitions.doc" \l "early_steps" Early Steps data forms - not required (Interventions/Appointments/Referrals) Section 8: Correspondence/Miscellaneous: Prior Written Notice forms Copies of correspondence sent out by Early Steps, record requests, notification of meetings/ appointments/missed appointments, referrals to services (to implement Individualized Family Support Plan or for transition from Early Steps) Copies of correspondence received by Early Steps: responses to referrals, requests for information, etc. If there is concern for the  HYPERLINK "http://www.cms-kids.com/home/resources/es_policy/Definitions.doc" \l "foster_parent" foster parent(s) who have provided consent, the names and  HYPERLINK "http://www.cms-kids.com/home/resources/es_policy/Definitions.doc" \l "personally_identifiable_information" personally identifiable information can be redacted from copies of the IFSP or copies of other related documents in the records before being released to the natural parent(s).  HYPERLINK "http://www.cms-kids.com/home/resources/es_policy/Attachments/12_Abbreviations_Acronyms_Records.pdf" Early Steps Abbreviations/ Acronyms Approved for Use in Early Steps Records HYPERLINK "http://www.floridahealth.gov/alternatesites/cms-kids/home/resources/es_policy/Attachments/3_Consent_for_screen_eval_assess_English.docx"Informed Notice and Consent for Screening, Evaluation, Assessment and Follow-Up Review - English  HYPERLINK "http://www.floridahealth.gov/alternatesites/cms-kids/home/resources/es_policy/Attachments/3_Consent_for_screen_eval_assess_Spanish.docx"Informed Notice and Consent for Screening, Evaluation, Assessment and Follow-Up Review-Spanish  HYPERLINK "http://www.floridahealth.gov/alternatesites/cms-kids/home/resources/es_policy/Attachments/3_Consent_for_screen_eval_assess_Creole.docx"Informed Notice and Consent for Screening, Evaluation, Assessment and Follow-Up Review-Creole HYPERLINK "http://www.floridahealth.gov/alternatesites/cms-kids/home/resources/es_policy/Attachments/1_Consent_for_use_of_insurance.docx"Informed Consent for the Use of Private Insurance-English  HYPERLINK "http://www.floridahealth.gov/alternatesites/cms-kids/home/resources/es_policy/Attachments/1_Consent_for_use_of_insurance_Spanish.docx"Informed Consent for the Use of Private Insurance-Spanish  HYPERLINK "http://www.floridahealth.gov/alternatesites/cms-kids/home/resources/es_policy/Attachments/1_Insurance_Information_Update_Letter_Creole.docx"Informed Consent for the Use of Private Insurance-Creole  HYPERLINK "http://www.cms-kids.com/home/resources/es_policy/8-ProceduralSafeguards/Comp8_Guide.doc" \l "G8_5_1" Operations Guide 8.5.1  HYPERLINK "http://www.cms-kids.com/home/resources/es_policy/12-DataRecordKeeping/Comp12_Handbook.doc" \l "P12_5_2" 12.5.2There may be limited items in the  HYPERLINK "http://www.cms-kids.com/home/resources/es_policy/Definitions.doc" \l "early_steps_record" Early Steps record for children for whom contact is not successful, eligibility is never determined, or an  HYPERLINK "http://www.cms-kids.com/home/resources/es_policy/Definitions.doc" \l "IFSP" IFSP is never developed.   HYPERLINK "http://www.cms-kids.com/home/resources/es_policy/12-DataRecordKeeping/Comp12_Handbook.doc" \l "P12_5_3" 12.5.3Progress reports summarize the services provided during a reporting period. Service documentation describing each encounter and service provided to an  HYPERLINK "http://www.cms-kids.com/home/resources/es_policy/Definitions.doc" \l "early_steps" Early Steps child or  HYPERLINK "http://www.cms-kids.com/home/resources/es_policy/Definitions.doc" \l "family" family member are different from progress reports. 12.7.0 Data Reporting Requirements - ESSO to U.S. DOE/OSEP HYPERLINK "http://www.cms-kids.com/home/resources/es_policy/12-DataRecordKeeping/Comp12_Handbook.doc" \l "P12_7_1" 12.7.1  HYPERLINK "http://www.cms-kids.com/home/resources/es_policy/Definitions.doc" \l "ESSO" ESSO will report on the number of infants and toddlers, ages birth through 2 (children who have not yet reached their third birthday), and their families receiving  HYPERLINK "http://www.cms-kids.com/home/resources/es_policy/Definitions.doc" \l "early_intervention_services" early intervention services under  HYPERLINK "http://www.cms-kids.com/home/resources/es_policy/Definitions.doc" \l "IDEA_PartC" IDEA, Part C according to an individualized family service plan ( HYPERLINK "http://www.cms-kids.com/home/resources/es_policy/Definitions.doc" \l "IFSP" IFSP) in place on a specific date. ESSO will report on the number of infants and toddlers with disabilities, ages birth through age 2, who exited IDEA, Part C services during a 12-month reporting period. All children who reached their third birthday while still receiving IDEA, Part C services should also be reported as exits. Only infants and toddlers who had an active individualized family service plan (IFSP) in place at some time during the State-determined 12-month reporting period are to be reported.       Early Steps Operations Guide 1/1/2018 This document does not include guidance/procedures for each policy in the Early Steps Policy Handbook. Guidance is included only as necessary to explain how to implement a policy, outline steps, or recommend actions to support implementation. PAGE  PAGE 4 Component 12 - Data Collection/Reporting and Record Keeping   ! 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