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130. Mass. Code Regs. 405.412. - Recordkeeping Requirements

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A community health center must comply with the requirements set forth by the Department on recordkeeping.  The community health center must specifically include in each patient’s medical record:

  1. the date of each service;
  2. patient’s name and date of birth;
  3. signature and title of person performing the services;
  4. patient’s medical history;
  5. diagnosis/chief complaint;
  6. indication of findings;
  7. medications given;
  8. treatment given;
  9. other recommended treatments;
  10. medical goods/supplies dispensed;
  11. tests administered and results;
  12. if hospitalization was ordered, a discharge summary;
  13. notation of all referrals and their outcomes.

If a patient does in fact visit the hospital, there must be an entry in the hospital’s medical record that corresponds to each visit made to the hospital by a particular patient for payment claims.  

Current as of June 2015