640.1 Policy 640 Documentation Requirements for Certification June 20, 2018 (Revised) POLICY Required certification information and activities shall be documented in a participant’s record in the data system. PURPOSE To assure that the required information and activities occurring during certification are documented in the data system. RELEVANT REGULATIONS 7 CFR §246.7—Certification of Participants 7 CFR §246.10 ¶(b)(2)(iii)—Supplemental Foods 7 CFR §246.10 ¶(e)—Food Delivery Systems OREGON WIC PPM REFERENCES

♦ 400—Local Program Overview: Responsibilities and Communications ♦ 600—Certification Introduction and Overview ♦ 635—Participant Notification: Eligibility and Rights & Responsibilities ♦ 636—Participant Notification: Ineligibility and Termination from WIC ♦ 641—Documentation Requirements for Certification in the Absence of a Data System APPENDICES Page 640.2 Appendix A Documentation Requirements for Certification Page 640.6 Appendix B Additional Documentation Required for Special Circumstances DEFINITIONS Applicant: An individual who comes to the WIC clinic requesting WIC services. State Requirement: An action required by the state WIC program due to state and federal requirements, USDA mandates that allow the state office to set local requirements, state grant assurances, and/or requirements from all state memorandums. USDA Requirement: An action required by USDA. The requirement is found in the published code of federal regulations (CFR) and/or USDA policy letters and/or all state memorandums (ASM).

Documentation Requirements for Certification, Continued 640.2 PROCEDURE Local Program Requirements 1.0 Local WIC programs will use the Oregon WIC data system for documentation of all information required for WIC certification. 1.1. Refer to the data system training manual for information about a screen, button or tab that is identified to complete a task. When the data system is unavailable 1.2. If the data system is unavailable, local programs may use paper certification forms to collect applicant or participant information. See 641— Documentation Requirements for Certification in the Absence of a Data System. Local forms 1.3. If a local program develops forms for certification purposes, the local program must get approval from the state WIC office before using the forms. State WIC staff will ensure that all required data is included for collection. See 400—Local Program Overview: Responsibilities and Communications for more information. 1.3.1. When state certification forms are revised, any similar forms developed by the local program must be revised and approved by the state WIC office within 60 days of the availability of the revised state form. Required Documentation 2.0 See Appendix A for a table that identifies where specific information must be documented in the data system. See Appendix B for additional documentation requirements in special circumstances. 2.1. When the documentation location is recommended rather than required, the local program must identify a location where all local staff will document the information to ensure consistency. Notification of Termination During Certification Period 3.0 A participant who is to be graduated from the WIC program at any time during the certification period shall be notified in writing not less than 15 days before the termination takes effect. Follow procedures for terminating participants during certification as described in 636— Participant Notification: Ineligibility and Termination from WIC. Other Required Documentation 4.0 At every certification or recertification visit, participants must sign the paper “Participant Signature Form” (form 57-629). This required documentation is not in the data system and must be obtained and retained according to 635—Participant Notification: Eligibility and Rights & Responsibilities.

Documentation Requirements for Certification, Continued 640.3

POLICY HISTORY Date * Revised, Reviewed, Released 7/13/2018 Released

The date located at the top of the policy is the date of the most recent release. Policies are to be implemented on release date and will become compliance findings 6 months from the release date. *Released: Significant changes made to policy. Release notes can be found in the corresponding document on the Policy and Procedure Manual page. Reviewed: The writer looked at this policy to make sure it was still accurate. Formatting changes may have occurred. Revised: Minor edits or formatting has occurred without need for release. USDA has accepted a policy and watermark is reviewed. Date of Origin: Date policy was initially released

If you need this in large print or an alternate format, please call 971-673-0040. This institution is an equal opportunity provider.

Documentation Requirements for Certification, Continued 640.4 APPENDIX A Documentation Requirements for Certification Type of interaction Information required for documentation Data System screen/tab title USDA requirement State requirement Applicant appearing in WIC clinic requesting an initial certification appointment and not certified at the time of the request Name Applicant Prescreen, Client Primary Screen x

Address Applicant Prescreen, Client Primary Screen x

Date request made Applicant Prescreen, Client Primary Screen x

Contact Type: Walk –in or Phone Applicant Prescreen, Intake

x Certification

Name Enrollment, Client Primary Screen x

WIC ID # Enrollment, Intake Screen x

Address Enrollment, Client Primary Screen x

Phone Enrollment, Client Primary Screen

x Text or Voice Message Enrollment, Client Primary Screen

x Date of birth Enrollment, Client Primary Screen x

Sex (M or F) Enrollment, Client Primary Screen x

Racial category(s) and Ethnic group of participant Enrollment, Client Primary Screen x

Certification category (e.g., WP, I, etc.) Enrollment, Intake x

Household size Enrollment, Income Eligibility Screen x

Income Enrollment, Income Eligibility Screen x

Documentation Requirements for Certification, Continued 640.5 Type of interaction Information required for documentation Data System screen/tab title USDA requirement State requirement

Certification, cont.

Enrollment in Food Stamps, TANF, or Medicaid/OHP Enrollment, Income Eligibility Screen x

Migrant status Enrollment, Intake Screen x

Voter Registration (women only) Enrollment, Intake Screen x

Delivery date for WP Enrollment, Intake x

Date of certification Enrollment, Intake Screen x

Date participant first appeared in clinic requesting WIC services See date request made x

Initials of the person responsible for determining income eligibility, if different from the competent professional authority making the nutritional risk determination User ID x

Date nutritional risk data collected Enrollment, Certification, Medical data, Health History, Diet Assessment, Risk Factor Screens x

Nutritional risk criteria Enrollment, Certification, Medical data, Health History, Diet Assessment, Risk Factor Screens x

Height or Length Enrollment, Certification, Medical Data Screen x

Weight Enrollment, Certification, Medical Data Screen x

Hemoglobin or hematocrit Enrollment, Certification, Medical Data Screen x

Documentation Requirements for Certification, Continued 640.6 Type of interaction Information required for documentation Data System screen/tab title USDA requirement State requirement Certification, cont.

Signature and title of the competent professional authority making the nutritional risk determination Enrollment, Certification, Medical data, Health History, Diet Assessment, Risk Factor Screens, Progress notes, User ID x

Trimester of pregnancy (prenatal women only)

Enrollment, Certification, Medical Data Screen

x Health history Enrollment, Certification, Health History Screen (See Notes) x Diet assessment Enrollment, Certification, Diet Assessment (See Notes) x WIC Transfer Card, if issued. A transfer card is provided if the participant is a member of a migrant farm-worker family or is likely to relocate during the certification period. Enrollment, Certification, Output, Documentation, WIC Transfer Card— (VOC) x

Food package prescribed to participant Enrollment, Certification, Food Package Assignment Screen x

Number of weeks breast fed Enrollment, Certification, Infant/Child Diet Assessment, Breastfeeding Tracking x

Nutrition Education Contact

Enrollment, Certification, NE Plan Screen x

Documentation Requirements for Certification, Continued 640.7 Type of interaction Information required for documentation Data System screen/tab title USDA requirement State requirement Certification, cont. Nutrition Goal/Next Steps Enrollment, Certification, NE Plan Screen

x Quarterly Nutrition Education Contact Scheduled Appointment Scheduler, Family Appointment Record

x

Ineligibility or graduation Date written notice of ineligibility or graduation was given Enrollment, Certification, Documentation, Graduation x

Signature and title of the clinic staff person making the decision Enrollment, Certification, Documentation, Graduation x

All reasons for ineligibility or graduation Enrollment, Certification, Documentation, Graduation x

Applicant notified in writing of all reasons for ineligibility or graduation and their right to a fair hearing - document that the notification was given Enrollment, Certification, Documentation, Graduation x

Waiting List Name Appointment Scheduler, Waiting List Screen x

Address and/or phone number Appointment Scheduler, Waiting List Screen x

Status (pregnant, breastfeeding, etc.) Appointment Scheduler, Waiting List Screen x

Documentation Requirements for Certification, Continued 640.8 Type of interaction Information required for documentation Data System screen/tab title USDA requirement State requirement Date placed on the waiting list Appointment Scheduler, Waiting List Screen x

NOTES: 1. Health History Although USDA does not require a specific health history form, the information obtained using a health history questionnaire is essential to establishing nutrition risks for eligibility, which is a USDA requirement. 2. Diet Assessment A complete diet assessment is essential for establishing nutrition risks for eligibility and is the basis for nutrition education. Completion of a diet assessment questionnaire is required at each certification for each participant.

Documentation Requirements for Certification, Continued 640.9 APPENDIX B Documentation Requirements for Certification The following table lists information that must be documented in the data system for special circumstances and whether the documentation location is required or recommended. For items with a recommended documentation location, the local program must identify a location where all local staff will document the information to ensure consistency. Situation requiring documentation Required location Recommended location Eligibility If “other” marked for the proof (i.e. proof of ID, residency or income) WIC Notes in Intake • Explain what proof used for “other”

Medical Data Referral data used for weight and height (i.e. physician’s office, hospital, etc.) Anthropometric Collection Date • Enter date anthropometric measurements were taken by referral source Medical Notes • Identify source of anthropometric measurements and date when the data was charted

Referral data used for biochemical information Biochemical Info Collection Date • Enter the date the blood work was taken by the referral source Medical Notes • Identify source of blood work and date when the data was charted

Refusal of height, weight, hemoglobin or hematocrit Medical Notes • Enter reason for refusal • Identify plan for obtaining the data at a later date in the WIC clinic or from a health care provider

Documentation Requirements for Certification, Continued 640.10 Situation requiring documentation Required location Recommended location Difficulty taking anthropometric or biochemical measurement Medical Notes • Enter reason for potentially inaccurate measurement or for inability to obtain the measurement • In unable to obtain a measurement, fill the field on the medical data screen with 9s

Premature infant Gestational Age Adjust Button • Enter “Yes” premature or early term and # of weeks gestation

Participant not physically present for a certification appointment Medical Data Tab, Medical Notes • Enter the reason an exception was granted to the physical presence requirement

Risk Factors Manually added low or medium risks

Health History or Diet Assessment Questionnaire Notes OR Progress Notes • Add justification for manually added risk Manually added high risks

Progress Notes • Add justification for manually added risk

Risk codes that apply to multiple types of health/medical conditions

Health History or Diet Assessment Questionnaire Notes OR Progress Notes • Add justification for risk

Documentation Requirements for Certification, Continued 640.11 Situation requiring documentation Required location Recommended location Nutrition Education Quarterly nutrition education documentation

Progress Notes for high risk follow-up OR Progress Notes or “Topics” field in the NE tab if not high risk • Document topics covered in individual education Breastfeeding Breastpump issuance Breastpump Tracking Tab • Enter required information for the type of breastpump issued

Formulas

Medical Documentation Food Package Assignment, Med Doc Button Pop-Up • Add the Medical Documentation information when required for a formula or special food package

Documentation Requirements for Certification, Continued 640.12 Situation requiring documentation Required location Recommended location High Risk

High risk care plan Progress Notes • RDN records the high-risk care plan. See Policy 661 for plan requirements. The SOAP format is encouraged. “S” = Subjective or client’s reported information or counselor’s observation “O” = Objective data is documented in Medical Data tab, not Progress Notes. “A” = Assessment of data “P” = Plan includes what was addressed during the appointment and actions the participant has identified to work on between visits. Can also include referrals made.

Referrals

Required referrals: Immunizations Health History Tab • Complete immunization questions to document required screening and referral

Required Referrals: Drug and Alcohol Use Referrals tab • When drug or alcohol use is reported, document referral to substance abuse programs

Required Referrals: Medicaid/Oregon Health Plan (OHP) Referrals tab • When a participant is not currently active on OHP, document referral

Documentation Requirements for Certification, Continued 640.13 Situation requiring documentation Required location Recommended location Other referrals

Referrals Tab • Documentation recommended for non- mandated referrals. Documentation of referrals can assist with participant follow-up and ensure any referral information offered is consistent. Progress Notes • May use to document the non-standard referrals not listed under the “Referrals” tab