Code of Massachusetts Regulations
130 CMR - DIVISION OF MEDICAL ASSISTANCE
Title 130 CMR 411.000 - Psychologist Services
Section 411.413 - Recordkeeping Requirements
Universal Citation: 130 MA Code of Regs 130.411
Current through Register 1531, September 27, 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.
(B) Release of information in the record is limited to the following:
(1) those instances required by federal or
state statute or regulation in accordance with the confidentiality provisions
of the profession; and
(2)
qualified personnel or consultants of the MassHealth agency or the U.S.
Department of Health and Human Services for the purpose of monitoring the
provision of services in accordance with 130 CMR 411.000.
Disclaimer: These regulations may not be the most recent version. Massachusetts may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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