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

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.