130. Mass. Code Regs. 410.409. - Recordkeeping (Medical Records) Requirements

Payment for any outpatient hospital services through MassHealth (Medicaid) is based on complete documentation in the patient’s medical record.  The outpatient hospital service must provide all medical records documenting services that are claimed to the MassHealth agency.  The medical record must have enough information to determine the nature, extend, quality and necessity of the treatments performed on each date of service.  The medical record must contain the following information:

1. the patient’s name and date of birth; 
2. a signed referral from a physician authorizing treatment;
3. date of each service;
4. name and title of person performing the services;
5. patient’s medical history;
6. diagnosis or complaint;
7. indication of findings;
8. tests administered and results;
9. treatment given;
10. medications given;
11. any anesthetic agent given;
12. medical goods/supplies dispensed;
13. other recommended treatments;
14. federally required consent for hysterectomy or sterilization;