Code of Massachusetts Regulations
130 CMR - DIVISION OF MEDICAL ASSISTANCE
Title 130 CMR 410.000 - Outpatient hospital services
Section 410.453 - Therapist Services: Recordkeeping Requirements

Universal Citation: 130 MA Code of Regs 130.410

Current through Register 1531, September 27, 2024

In addition to the information required in 130 CMR 410.409, the member's record must include the following:

(A) a licensed physician's or licensed nurse practitioner's written referral for evaluation, referral for treatment, and renewal of referral (if applicable) every 60 days (see 130 CMR 410.451(B));

(B) the written comprehensive evaluation report (see 130 CMR 410.451(C));

(C) the name, address, and telephone number of the member's primary physician;

(D) a treatment notation for each date on which therapy was provided that includes at least the following:

(1) the specific therapeutic procedures and methods used;

(2) the amount of time spent in treatment; and

(3) the signature and title of the person who provided the service;

(E) at least weekly documentation of the following:

(1) the member's response to treatment;

(2) any changes in the member's condition;

(3) the problems encountered or changes in the treatment plan or goals, if any;

(4) the location where the service was provided if different from that in the evaluation report; and

(5) the signature and title of the therapist; and

(F) a discharge summary, when applicable.

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