Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 462.000 - Licensed Independent Clinical Social Work Services › Section 462.410 - Recordkeeping Requirements

Current through Register 1525, July 5, 2024
(A) Payment for any
			 service listed in
			 130 CMR
			 462.000 is conditioned upon its full and complete
			 documentation in the member's medical record. The licensed independent clinical
			 social worker must maintain an electronic or hard copy record of all licensed
			 independent clinical social work 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
			 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 service including date of initial contact;
(2) 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;
(3) the name and
			 address of the member's primary care physician or, if not available, another
			 physician who has treated the member;
(4) the member's description of the problem,
			 and any additional information from other sources, including the referral
			 source, if any;
(5) the events
			 precipitating contact with the licensed independent clinical social
			 worker;
(6) the relevant medical,
			 psychosocial, educational, and vocational history;
(7) a comprehensive diagnostic services
			 evaluation of the member at intake and semiannually thereafter;
(8) the clinical impression of the member and
			 a diagnostic formulation, including a specific diagnosis using standard
			 nomenclature;
(9) a listing of
			 realistic long-range goals, and a time frame for their achievement;
(10) a listing of short-term objectives,
			 which must be established in such a way as to lead toward accomplishment of the
			 long-range goals;
(11) the proposed
			 schedule of therapeutic activities necessary to achieve such goals and
			 objectives and the responsibilities of each individual member of the
			 interdisciplinary team;
(12) a
			 schedule of dates for utilization review to determine the member's progress in
			 accomplishing goals and objectives;
(13) the name, qualifications, and discipline
			 of the licensed independent clinical social worker responsible for the
			 member.
(14) a written record of
			 quarterly reviews by the licensed independent clinical social worker, which
			 relate to the short- and long-range goals;
(15) all information and correspondence
			 regarding the member, including appropriately signed and dated consent
			 forms;
(16) a medication-use
			 profile;
(17) 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
(18) for members
			 younger than 21 years old, a CANS completed during the initial behavioral
			 health assessment and updated at least every 90 days thereafter.