Mental Health Services: Recordkeeping Requirements

(A) The hospital outpatient department must obtain, upon the initiation of treatment, written authorization from each member or the member's legal guardian to release information obtained by the provider to hospital staff, federal and state regulatory agencies, and, when applicable, referral providers, to the extent necessary to carry out the purposes of the program and to meet regulatory requirements, including provider audits. (B) In addition to the information required in 130 CMR 434.410, each member's record must include the following information: (1) the member's case number, address, telephone number, sex, age, marital status, next of kin, and school or employment status (or both); (2) the date of initial contact and, if applicable, the referral source; (3) a report of a physical examination performed within six months (if such an examination has not been performed in that period, one must be given within 30 days after the member's request for services or, if the member refuses to be examined, the record must document the reasons for the exam postponement); (4) the name and address of the member's primary physician or medical clinic (a physician or medical clinic must be recommended if there is not one currently attending the member); (5) a description of the nature of the member's condition; (6) the relevant medical, social, educational, and vocational history; (7) a comprehensive functional assessment of the member; (8) the clinical impression of the member and a diagnostic formulation, including a specific diagnosis using DSM IV diagnosis codes; (9) the member's treatment plan, updated as necessary, including long-range goals, short-term objectives, and the proposed schedule of therapeutic activities; (10) a schedule of dates for utilization review to determine the member's progress in accomplishing goals and objectives; (11) the name, qualifications, and discipline of the primary therapist; (12) a written record of utilization reviews by the primary therapist; (13) documentation of each visit, including the member's response to treatment, written and signed by the person providing the service, and including the therapist's discipline and degree; (14) all information and correspondence regarding the member, including appropriately signed and dated consent forms; (15) a medication-use profile; (16) when the member is discharged, a discharge summary; and (17) for members under the age of 21, a copy of the CANS completed during the initial behavioral-health assessment and updated at least every 90 days thereafter. (C) A brief history is acceptable for emergency or walk-in visits when the treatment plan does not call for extended care.