(A) The hospital outpatient department must
obtain, upon the initiation of treatment, written authorization from each
member or the member's legal guardian to release information obtained by the
provider to hospital staff, federal and state regulatory agencies, and, when
applicable, referral providers, to the extent necessary to carry out the
purposes of the program and to meet regulatory requirements, including provider
audits.
(B) In addition to the
information required in
130 CMR
434.410, each member's record must include
the following information:
(1) the member's
case number, address, telephone number, sex, age, marital status, next of kin,
and school or employment status (or both);
(2) the date of initial contact and, if
applicable, the referral source;
(3) a report of a physical examination
performed within six months (if such an examination has not been performed in
that period, one must be given within 30 days after the member's request for
services or, if the member refuses to be examined, the record must document the
reasons for the exam postponement);
(4) the name and address of the member's
primary physician or medical clinic (a physician or medical clinic must be
recommended if there is not one currently attending the member);
(5) a description of the nature of the
member's condition;
(6) the
relevant medical, social, educational, and vocational history;
(7) a comprehensive functional assessment of
the member;
(8) the clinical
impression of the member and a diagnostic formulation, including a specific
diagnosis using DSM IV diagnosis codes;
(9) the member's treatment plan, updated as
necessary, including long-range goals, short-term objectives, and the proposed
schedule of therapeutic activities;
(10) a schedule of dates for utilization
review to determine the member's progress in accomplishing goals and
objectives;
(11) the name,
qualifications, and discipline of the primary therapist;
(12) a written record of utilization reviews
by the primary therapist;
(13)
documentation of each visit, including the member's response to treatment,
written and signed by the person providing the service, and including the
therapist's discipline and degree;
(14) all information and correspondence
regarding the member, including appropriately signed and dated consent
forms;
(15) a medication-use
profile;
(16) when the member is
discharged, a discharge summary; and
(17) for members under the age of 21, a copy
of the CANS completed during the initial behavioral-health assessment and
updated at least every 90 days thereafter.
(C) A brief history is acceptable for
emergency or walk-in visits when the treatment plan does not call for extended
care.
