Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 423.000 - Freestanding Ambulatory Surgical Centers › Section 423.413 - Recordkeeping Requirements

Current through Register 1525, July 5, 2024
Surgical centers must maintain a medical-record system
				promoting quality and confidential patient care in accordance with
				105 CMR
				140.000:
Licensure of Clinics
. This
				system must collect and retain data in a comprehensive and efficient manner and
				permit the prompt retrieval of information. Accurate and complete medical
				records must be maintained for each member receiving surgical services from the
				surgical center. The data maintained in the member's medical record must also
				be sufficient to justify any further diagnostic procedures, treatments,
				recommendations for return visits, and referrals. The medical record must be
				clear and legible, and readily accessible to health care practitioners and the
				MassHealth agency. The medical record must be maintained by the surgical center
				for six years.
(A)
Documentation
. Payment for any service covered by
			 MassHealth is conditioned upon its full and complete documentation in the
			 member's medical record. Payment for maintaining the member's medical record is
			 included in the fee for the facility component. Each medical record must
			 contain sufficient information to fully document the nature, extent, quality,
			 and necessity of the care furnished to the member for each date of service
			 claimed for payment. If the information in the member's record is not
			 sufficient to document the service for which payment is claimed by the
			 provider, the MassHealth agency will not pay for the service or, if payment has
			 been made, may consider such payment to be an overpayment subject to recovery
			 as defined in the MassHealth administrative and billing regulations in
			 130 CMR 450.000:
Administrative and Billing Regulations
. The medical record
			 requirements in
			 130 CMR 423.000 constitute
			 the standard against which the adequacy of records will be measured, as set
			 forth in
			 130 CMR 450.000:
Administrative and Billing Regulations
.
(B)
Components
. The
			 medical record must include the following:
(1)
			 patient identification, including name, date of birth, and the member's
			 MassHealth identification number;
(2) medical history and dental history, as
			 appropriate;
(3) findings of
			 physical examination and preoperative diagnosis;
(4) results of any preoperative diagnostic
			 studies (entered before surgery) if ordered, including laboratory and
			 radiologic reports. These results include dated and mounted X rays, if
			 applicable;
(5) operative record
			 documenting clinical findings, techniques of the operation, intraoperative
			 medications administered, and type of surgical procedure;
(6) pathologist's reports on tissue removed
			 in surgery, except those exempted by the governing body;
(7) date of surgery;
(8) surgeon's name, address, and telephone
			 number;
(9) allergies and adverse
			 drug reactions;
(10) anesthesia
			 record describing anesthetic agents used, dosages administered, and
			 documentation of start and end times of general or intravenous
			 anesthesia;
(11) nursing notes
			 (preoperative, intraoperative, and postoperative, including documentation of
			 any medical goods or supplies dispensed);
(12) patient's surgical consent, with
			 documentation of it as properly executed informed consent;
(13) postoperative diagnosis;
(14) discharge summary, including
			 recommendations and referrals for additional treatment or consultations, when
			 applicable; and
(15) records
			 pertaining to requests for laboratory, radiologic, and/or pathology information
			 requested in relation to the surgical procedure.