A. ANNUAL EXAMINATIONS

All clients shall have the opportunity for an annual physical examination, dental examination, and eye examination. If the client or client’s guardian does not want an annual physical, eye or dental examination, the Team Leader will request that the client or the client’s guardian submit a written statement which describes their declination of such service. The original statement declining the annual examination(s) shall be kept in the client’s file at the main office. A copy of the declination shall be kept in the client’s notebook.

Clients of DDD must not pay for health care needs not covered by Medicaid unless:

  1. DSHS has denied payment or does not cover the item/service,
  2. A copy of the denial or statement of non-coverage has been sent to the DD Case Manager along with a request that DDD cover the item/service, and
  3. DDD also refuses to pay for the item/service.

B. FACE SHEET

The current due dates for annual physicals, eye and dental examinations will be listed on the client’s face sheet. It is the Client Service Coordinator’s responsibility to ensure that the client’s face sheet is kept current.

C. DOCUMENTATION OF MEDICAL VISITS

All doctor, therapy, dentist and psychiatric appointments should be recorded on the “Medical Contact Record” form for each client. These notes shall be completed after each health care appointment and include the following information:

  1. The full date, including month/day/year.
  2. The reason for the health care visit.
  3. The name of the health care practitioner.
  4. The results of the health care appointment, including a description of any medications and the actions a client is advised to take as a result of the health care visit.
  5. The date for any follow-up appointments.
  6. The signature of the person making the entry.