Documentation – How to document your completed steps

Documenting Your Completed Compliance Steps

Remember that you can also find step-by-step information in your program's comprehensive PDF compliance guide, available on your dedicated resource page! As you know from other tutorials, completing steps is not enough to achieve compliance - you also need to obtain appropriate and complete documentation of those steps. The video tutorial and accompanying information below walk you through all you need to know about the documentation phase of the compliance process including what documents you may need, where to find them, and what needs to be included.

 

 

Quick Tips in Review

After you’ve completed the steps required for compliance, it’s time to move onto phase two of the compliance process: Documenting your completed steps. Complete documentation for each requirement is essential for compliance, and it’s your responsibility to obtain the documentation you need from your healthcare provider or other sources. Sometimes this means being persistent and insistent because not all standard documents include all the required information. Be particularly careful when taking screenshots from your patient portal.

Examples of the types of documents you’ll need include but are not limited to lab reports for completed titer tests, documentation of immunizations received, lab reports or results from TB testing, health insurance card, UConn physical exam form, and CPR certification card. You may be able to access some of these documents from your patient portal. Others may come directly from your provider.

In general, all documents must include:

  • Your name (first and last) and provider information
  • Relevant date(s) and service performed (examples: type of test, immunization received)
  • Results (if relevant)
  • For MMR, Varicella, and Hepatitis B titers, documentation must include either:
    • Qualitative test results (examples: positive, negative, equivocal)
    • Quantitative test results with a reference range to interpret the numerical value
  • For flu shots, your documentation must also include the vaccine brand name or manufacturer and the vaccine lot #

Download PDF documents from your patient portal, use your browser’s Print to PDF option, scan or photograph printed documents, or take screenshots. No matter how you prepare your documents, double check that all required datapoints are visible and legible. Incomplete documents will be rejected by Complio – no exceptions! We strongly recommend creating a folder to collect all your compliance documents and giving each file a descriptive name that easily shows what it contains. This will help you stay organized and make the submission process easier!