Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 411.000 - Psychologist Services › Section 411.413 - Recordkeeping Requirements

Current through Register 1525, July 5, 2024
(A) Payment for any
			 service listed in
			 130 CMR
			 411.000 is conditioned upon its full and complete
			 documentation in the member's medical record. The psychologist must maintain an
			 electronic or hard copy record of all services provided to a member for a
			 period of at least six years following the date of service, subject to any
			 applicable federal or state standard requiring a longer retention period. For
			 all psychological services, the record must contain the following information:
(1) the member's name and case number,
			 MassHealth identification number, address, telephone number, sex, age, date of
			 birth, marital status, next of kin, school or employment status (or both), and
			 date or dates of services, including date of initial contact;
(2) the ordering source, if
			 applicable;
(3) the reason for the
			 order or visit;
(4) For
			 psychological assessments, the record must also contain the following:
(a) a brief description of behavioral
			 observations, and any relevant personal information elicited during
			 assessment;
(b) the original
			 responses to all psychological assessments completed;
(c) a summary of scores;
(d) a comprehensive written report describing
			 the psychological assessment and interpretation of responses; and
(e) documentation of compliance with the
			 requirements of
			 130
			 CMR 411.412.
(5) For psychological treatment services, the
			 record must also contain the following:
(a) a
			 report of a physical examination performed within six months of the date of
			 intake or documentation that the member did not want to be examined and any
			 stated reason for that preference;
(b) the name and address of the member's
			 primary care physician or, if not available, another physician who has treated
			 the member;
(c) the member's
			 description of the problem, and any additional information from other sources,
			 including the referral source, if any;
(d) the events precipitating contact with the
			 psychologist;
(e) the relevant
			 medical, psychosocial, educational, and vocational history;
(f) a comprehensive diagnostic services
			 evaluation of the member at intake and semiannually thereafter;
(g) the clinical impression of the member and
			 a diagnostic formulation, including a specific diagnosis using standard
			 nomenclature;
(h) a listing of
			 realistic long-range goals, and a time frame for their achievement;
(i) a listing of short-term objectives, which
			 must be established in such a way as to lead toward accomplishment of the
			 long-range goals;
(j) the proposed
			 schedule of therapeutic activities necessary to achieve such goals and
			 objectives and the responsibilities of each individual member of the
			 interdisciplinary team;
(k) a
			 schedule of dates for utilization review to determine the member's progress in
			 accomplishing goals and objectives;
(l) a written record of quarterly reviews by
			 the psychologist, which relate to the short-and long-range goals;
(m) all information and correspondence
			 regarding the member, including appropriately signed and dated consent
			 forms;
(n) a medication-use
			 profile;
(o) when the member is
			 discharged, a discharge summary, including a recapitulation of the member's
			 treatment and recommendations for appropriate services concerning follow-up as
			 well as a brief summary of the member's condition and functional performance on
			 discharge; and
(p) for members
			 younger than 21 years old, a CANS completed during the initial behavioral
			 health assessment and updated at least every 90 days thereafter.