Recordkeeping Requirements

(A) Member Records. (1) Psychiatric day treatment programs must maintain member records in accordance with 130 CMR 450.205: Recordkeeping and Disclosure, in addition to applicable recordkeeping requirements for clinics under M.G.L. c. 111 § 70, and 105 CMR 140.302: Patient Records. (2) Member records must be complete, accurate, and properly organized. (3) In community health centers, the psychiatric day treatment program’s records must be integrated with the member’s overall records. (4) The member’s record must include at least the following information: (a) all identifying data; (b) a report of an examination performed by a physician within six months of the time of admission. If no such current examination exists, one must be performed within 30 days after the member’s request for services. It is the responsibility of the psychiatric day treatment case coordinator to ensure that arrangements are made for such an exam. If the member resists the examination, the member’s record must document the reasons for postponement; (c) the name and address of the member’s primary physician or medical clinic. The program must locate a physician or medical clinic for the member if the member is currently without one; (d) a description of the member’s psychiatric condition as indicated by the member and others, including the referral source, if any; (e) the events that precipitated the member’s referral; (f) a comprehensive statement of the member’s physical, psychosocial, social, economic, educational, and vocational assets and disabilities, stated in terms of the functional skill level of the member and a summary of the member’s treatment response; (g) the clinical impression and formulation, including diagnosis; (h) short- and long-range goals that are realistic and obtainable, and a time frame for their achievement; (i) a schedule of activities and therapies, both in and out of the program, necessary to achieve the member’s goals and the responsibilities of each member of the treatment team; (j) the prescribed schedule for attendance and a record of the member’s actual attendance; (k) a schedule of review dates to occur no less than every 90 days to reassess the member’s progress in accomplishing goals and overall treatment response; (l) a written record of the reassessments required in 130 CMR 417.437(E)(11) that includes recommendations for revision of the treatment plan, when indicated, and the names of the reviewers; (m) the name of the case coordinator; (n) weekly notes by the case coordinator as well as notes by the staff physician and other staff members significantly involved in the treatment plan; (o) reports on all conferences with family, friends, and outside professionals; (p) all information and correspondence to and from other involved agencies, including appropriately signed and dated consent forms, including the written authorization described at 130 CMR 417.437(B); (q) a drug-use profile (both prescribed and other); and (r) when discharged, a discharge summary, including a recapitulation of the member’s treatment, a brief summary of the member’s condition and response to treatment on discharge, achievement of treatment and recovery goals, and recommendations for appropriate services that should be provided in subsequent programs by the same or other agencies to accomplish the member’s long-range treatment goals, and the program's future responsibility for the member’s care. (B) Program Records. The psychiatric day treatment program must also retain documentation reflecting compliance with the requirements of 130 CMR 417.000, including 130 CMR 417.438 and 130 CMR 417.439. (C) Availability of Records. Any and all records shall be made available to the MassHealth agency, upon request.