130 C.M.R. 485.413 – Recordkeeping Requirements

(A) Payment for any service listed in 130 CMR 485.000 is conditioned upon its full and complete documentation in the member’s medical record. The sterilization clinic must maintain a record of all medical services provided to a member for at least six years following the date of service. See also the requirement contained in 130 CMR 485.411(C)(2).

Commonwealth of Massachusetts Subchapter Number and Title Page

MassHealth 4. Program Regulations

4-5

Provider Manual Series (130 CMR 485.000)

Transmittal Letter Date

Sterilization Clinic Manual

STR-18 01/02/15

(B) The medical record must contain, but is not limited to, the following information:
1. (1) the member’s name, address, telephone number, date of birth, and MassHealth identification number;
2. (2) the date of service;
3. (3) the name, title, and signature of the person performing the service;
4. (4) the type of visit;
5. (5) medical history and history update;
6. (6) pertinent findings on examination;
7. (7) laboratory tests and results;
8. (8) abnormal findings and follow-up treatment;
9. (9) drugs administered or prescribed, including strength, dosage, route, regimen, and number of refills;
10. (10) drugs dispensed, including strength, dosage, route, regimen, and number of units;
11. (11) the contraceptive method used and any special instructions;
12. (12) a summary of counseling; and
13. (13) plans for follow-up.
(C) Basic information collected during previous visits with the member (for example, identifying data or medical history) does not need to be repeated in the medical record for subsequent visits as long as the entire medical record reflects continuity of care.

REGULATORY AUTHORITY

130 CMR 485.000: M.G.L. c. 118E, §§7 and 12.