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TIPS FOR EFFECTIVE DOCUMENTATION OF A HOME VISIT

All WV Birth to Three providers and service coordinators are responsible for documenting
information when engaging with a family relative on the services that are being provided to them. It
is also important to document the conversations and activities that occurred as part of the home
visit with the child and family.

Forms for WVBTT documentation of services include the Intervention Activity Note, the Service
Coordination Note and the Correspondence/Phone Log. Direct Service Providers complete the
Intervention Activity Note and Service Coordinators complete the Service Coordination Activity
Note. Non face-to-face activities such as corresponding with the child’s physician with the family’s
permission or coordinating a transition conference are to be documented on the Correspondence/

Phone Log.

IMPORTANT DO’S AND DON’TS FOR REQUIRED DOCUMENTATION

DO DON’T

Refer to WV Birth to Three policy and Do not rely on what other practitioners have
procedures for specific documentation told you is your responsibility for
requirements. Practitioner and service documentation.
coordinator documentation expectations are
defined.

Documentation is to be provided to the family Do not rely on your family to remember all

via secured/encrypted email or snail mail. that is discussed with your visit.

Include parent’s questions or concerns and Do not base your comments on your
their child’s response to strategies and observation alone.
progresses that their child is making.

Attest that you have completed the Do not complete documentation prior to a

documentation with the family and sign to that face-to-face meeting or virtual meeting with

fact. the family.

Complete the Intervention Activity Note or the Avoid using short hand or “jargon” when
Service Coordination Note documenting the documenting your visit. Remember the
service provided as it applies to an outcome. If family also receives a copy and may not be
necessary, another practitioner should be able clear on the meaning of your
to pick up your notes and continue with a documentation.
service.

Use appropriate billing codes. Your submitted Do not bill for services prior to completing
documentation should support the service that and uploading documentation to WVBTT
was provided to your family during the home Online. This is documented in your Rider
visit. Agreement with WVBTT. As a checks and
balance system, families receive an
Explanation of Benefits (EOB) for services that
have been provided.

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