Recordkeeping Requirements

(A) A CHC must comply with the MassHealth agency’s recordkeeping regulation contained in 130 CMR 450.000: Administrative and Billing Regulations. In addition, each member's medical record must include the reason for each visit and the data upon which the diagnostic impression or statement of the member's problem is based, and must be sufficient to justify any further diagnostic procedures, treatments, and recommendations for return visits or referrals. Specifically, a medical record must include, but not be limited to (1) the date of each service; (2) the member's name and date of birth; (3) the signature and title of the person performing the services; (4) the member's medical history; (5) the diagnosis or chief complaint; (6) clear indication of all findings, whether positive or negative, on examination; (7) any medications administered or prescribed, including strength, dosage, and regimen; (8) a description of any treatment given; (9) recommendations for additional treatments or consultations, when applicable; (10) any medical goods or supplies dispensed or prescribed; (11) any tests administered and their results; (12) a notation of hospitalization ordered by a CHC practitioner and discharge summaries from such hospitalization; and (13) notations of all referrals and results of referrals, including the referral provider's diagnoses, treatment plans, test results, and medical outcomes. (B) Basic data collected during previous visits (for example, identifying data, chief complaint, and history) need not be repeated in the member's medical record for subsequent visits. However, data that fully document the nature, extent, quality, and necessity of care furnished to a member must be included for each service for which payment is claimed, along with any data that update the member's medical course. It is not necessary to include a full medical history in the medical record for any member who is seen by the CHC on a one-time emergency basis. (C) For hospital visit services, there must be an entry in the hospital medical record corresponding to and substantiating each hospital visit for which payment is claimed. An inpatient medical record documents services provided to members and billed to the MassHealth agency if it conforms to and satisfies the medical records requirements set forth in the current Rules and Regulations for Hospitals in Massachusetts issued by the Massachusetts Department of Public Health. The CHC claiming payment for a hospital inpatient visit is responsible for the adequacy of the medical record documenting such visit. The physician must sign the entry in the hospital medical record that documents the findings of the comprehensive history and physical examination. (D) Additional medical records requirements for other services can be found in the applicable sections of the MassHealth agency’s regulations.