Recordkeeping Requirements

(A) A record must be established and maintained for each member that is consistent with current professional standards. The record must include the following documents, if applicable: (1) the screening certification from a screening team, as described in 130 CMR 425.406, or appropriate court documentation for court-ordered admissions, pursuant to M.G.L. c. 123, §§ 7, 8, 12a, and 12b; (2) the treatment plan, as described in 130 CMR 425.416; (3) documentation from the hospital interdisciplinary review team supporting the need for continuing care, as described in 130 CMR 425.417; (4) the discharge plan, as described in 130 CMR 425.418; and (5) for members younger than 21 years of age, a copy of the CANS completed during the discharge planning process. (B) No information from the medical record may be released to other providers without a signed authorization form from the member, or his or her legal guardian. (C) Psychiatric inpatient hospitals must adhere to all laws and regulations relating to recordkeeping requirements, including but not limited to the confidentiality regulations in 130 CMR 425.424 and the recordkeeping and disclosure requirements of 130 CMR 450.205: Recordkeeping and Disclosure. (D) A member's records must be maintained by the psychiatric inpatient hospital for a period of six years following the date of discharge. (E) If any litigation, claim, negotiation, audit, or other action involving the records is commenced prior to the expiration of the applicable retention period, all records must be retained until completion of the action and resolution of all issues resulting therefrom, or until the end of the applicable retention period, whichever is later.