Therapist Services: Recordkeeping Requirements

In addition to the information required in 130 CMR 410.409, the member's record must include the following: (A) a licensed physician's or licensed nurse practitioner’s written referral for evaluation, referral for treatment, and renewal of referral (if applicable) every 60 days (see 130 CMR 410.451(B)); (B) the written comprehensive evaluation report (see 130 CMR 410.451(C)); (C) the name, address, and telephone number of the member's primary physician; (D) a treatment notation for each date on which therapy was provided that includes at least the following: (1) the specific therapeutic procedures and methods used; (2) the amount of time spent in treatment; and (3) the signature and title of the person who provided the service; (E) at least weekly documentation of the following: (1) the member's response to treatment; (2) any changes in the member's condition; (3) the problems encountered or changes in the treatment plan or goals, if any; (4) the location where the service was provided if different from that in the evaluation report; and (5) the signature and title of the therapist; and (F) a discharge summary, when applicable. (130 CMR 410.454 Reserved) 4. Program Regulations