Recordkeeping Requirements

(A) The IDTF is responsible for ensuring the medical necessity of the tests and maintaining test results in the member’s health record. (B) IDTFs must maintain a medical-record system promoting quality and confidential member care in accordance with Massachusetts Department of Public Health regulations at 105 CMR 140.000: Licensure of Clinics. This system must collect and retain data in a comprehensive and efficient manner and permit the prompt retrieval of information. Accurate and complete medical records must be maintained for each member receiving testing services from the IDTF. The data maintained in the member's medical record must also be sufficient to justify any further diagnostic procedures. The medical record must be clear and legible, and readily accessible to health-care practitioners and the MassHealth agency. The medical record must be maintained by the IDTF for at least six years. (C) The medical record must contain, at a minimum, the following information: (1) the member's name, address, telephone number, date of birth, and MassHealth identification number; (2) the date of service; (3) the name, title and signature of the referring clinician; (4) a written order for the tests to be performed; (5) the name, title, and signature of the person performing the service; (6) the name of the supervising physician; (7) pertinent findings on examination; and (8) tests performed and results.