Effective Date
Instructions
Updated: 5/2026
Purpose
The service provider uses the service delivery log for Preadmission Screening and Resident Review (PASRR) to document activities and objectives worked on during the provided intellectual and developmental disability (IDD) habilitative specialized service.
Procedure
The IDD habilitative specialized service provider completes the service delivery log to document the objectives that were worked on for the specified person. The IDD habilitative specialized service provider must maintain a copy of the completed form in the person’s record until notified by HHSC.
Detailed Instructions
Person’s Last Name — Enter the person’s last name.
Person’s First Name — Enter the person’s first name.
Person’s Medicaid No. — Enter the person’s nine-digit Medicaid number.
Service Provider — Enter the service provider’s name.
Type of Service — Select the type of IDD habilitative specialized service.
Service Month and Year — Enter the month and year the service was provided.
Service Delivery Details
Date — Enter the date the service was provided.
Begin Time — Enter the begin time of the service provided.
End Time — Enter the end time of the service provided.
Total Time — Enter the total length of time the service was provided.
Service Location — Enter the location where the service was delivered.
Summary — Enter the objectives worked on during the provided service and any major activities that occurred. Provide details of any critical incidents or significant observations.
Progress or no progress toward the outcome — Enter if progress was made during the service delivery.
Follow up needed — Enter plans for the next service if applicable.
Printed Name — Enter the service provider’s full name.
Signature and Title — The service provider signs the form and enters their title.