Additional Recordkeeping Requirements

In addition to the requirements at 105 CMR 140.302, clinics with a licensed mental health service must comply with the following: (A) Documentation of the delivery of mental health services, which may include substance use disorder treatment, including progress notes or statements recorded by the mental health professionals who are responsible for implementing the patient’s treatment plan. In the case of unlicensed clinicians recording progress notes or implementing treatment plans, a licensed clinician is responsible for clinical oversight of all clinical activities. (B) Patient records must be created and maintained in accordance with all federal and state laws, regulations, and requirements applicable to the services provided.