Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 417.000 - Psychiatric Day Treatment Program Manual › Section 417.437 - Recordkeeping Requirements

Current through Register 1525, July 5, 2024
(A)
Member Records
.
(1)
			 Psychiatric day treatment programs shall maintain member records in accordance
			 with
			 130 CMR
			 450.205:
Recordkeeping and
			 Disclosure,
in addition to applicable recordkeeping requirements for
			 clinics under M.G.L. c. Ill § 70, and
			 105 CMR
			 140.302(2).
(2) Member records must be complete,
			 accurate, and properly organized.
(3) In community health centers, the
			 psychiatric day treatment program's records must be integrated with the
			 member's overall records.
(4) The
			 member's record must include at least the following information:
(a) all identifying data;
(b) a report of an examination performed by a
			 physician within six months of the time of admission. If no such current
			 examination exists, one must be performed within 30 days after the member's
			 request for services. It is the responsibility of the psychiatric day treatment
			 case coordinator to ensure that arrangements are made for such an exam. If the
			 member resists the examination, the member's record must document the reasons
			 for postponement;
(c) the name and
			 address of the member's primary physician or medical clinic. The program must
			 locate a physician or medical clinic for the member if the member is currently
			 without one;
(d) a description of
			 the member's psychiatric condition as indicated by the member and others,
			 including the referral source, if any;
(e) the events that precipitated the member's
			 referral;
(f) a comprehensive
			 statement of the member's physical, psychosocial, social, economic,
			 educational, and vocational assets and disabilities, stated in terms of the
			 functional skill level of the member and a summary of the member's treatment
			 response;
(g) the clinical
			 impression and formulation, including diagnosis;
(h) short- and long-range goals that are
			 realistic and obtainable, and a time frame for their achievement;
(i) a schedule of activities and therapies,
			 both in and out of the program, necessary to achieve the member's goals and the
			 responsibilities of each member of the treatment team;
(j) the prescribed schedule for attendance
			 and a record of the member's actual attendance;
(k) a schedule of review dates to occur no
			 less every 90 days to reassess the member's progress in accomplishing goals and
			 overall treatment response;
(l) a
			 written record of the reassessments required in
			 130 CMR 417.437(E)(11)
			  that includes recommendations for revision
			 of the treatment plan, when indicated, and the names of the
			 reviewers;
(m) the name of the case
			 coordinator;
(n) weekly notes by
			 the case coordinator as well as notes by the staff physician and other staff
			 members significantly involved in the treatment plan;
(o) reports on all conferences with family,
			 friends, and outside professionals;
(p) all information and correspondence to and
			 from other involved agencies, including appropriately signed and dated consent
			 forms, including the written authorization described at
			 130 CMR
			 417.437(B);
(q) a drug-use profile (both prescribed and
			 other); and
(r) when discharged, a
			 discharge summary, including a recapitulation of the member's treatment, a
			 brief summary of the member's condition and response to treatment on discharge,
			 achievement of treatment and recovery goals, and recommendations for
			 appropriate services that should be provided in subsequent programs by the same
			 or other agencies to accomplish the member's long-range treatment goals, and
			 the program's future responsibility for the member's
			 care.