Code of Massachusetts Regulations
130 CMR - DIVISION OF MEDICAL ASSISTANCE
Title 130 CMR 436.000 - Radiation Oncology Treatment Centers
Section 436.417 - Recordkeeping Requirements

Universal Citation: 130 MA Code of Regs 130.436

Current through Register 1531, September 27, 2024

(A) The radiation oncology center is responsible for ensuring the medical necessity of the services and maintaining test results in the patient's health record.

(B) Radiation oncology centers must maintain a medical-record system promoting quality and confidential patient care in accordance with Massachusetts Department of Public Health regulations at 105 CMR 140.000. 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 testing services from the radiation oncology center. The data maintained in the member's medical record must also be sufficient to justify any further diagnostic procedures. 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 radiation oncology center for at least six years.

(C) The medical record must contain, at a minimum, the following information:

(1) the member's name, address, telephone number, date of birth, and MassHealth identification number;

(2) the date of service;

(3) the name, title and signature of the referring physician;

(4) a written order for the tests or treatment to be performed;

(5) the name, title, and signature of the person performing the service;

(6) the name of the supervising physician;

(7) pertinent findings on examination; and

(8) the tests and treatment performed and the respective results.

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