Section 410.453 - Therapist Services: Recordkeeping RequirementsIn addition to the information required in 130 CMR 410.409, the member's record must include the following:
(A) a licensed physician's or licensed nurse practitioner's written referral for evaluation, referral for treatment, and renewal of referral (if applicable) every 60 days (see130 CMR 410.451(B));(B) the written comprehensive evaluation report (see130 CMR 410.451(C));(C) the name, address, and telephone number of the member's primary physician;(D) a treatment notation for each date on which therapy was provided that includes at least the following: (1) the specific therapeutic procedures and methods used;(2) the amount of time spent in treatment; and(3) the signature and title of the person who provided the service;(E) at least weekly documentation of the following:(1) the member's response to treatment;(2) any changes in the member's condition;(3) the problems encountered or changes in the treatment plan or goals, if any;(4) the location where the service was provided if different from that in the evaluation report; and(5) the signature and title of the therapist; and(F) a discharge summary, when applicable.Amended by Mass Register Issue 1344, eff. 7/28/2017.Amended by Mass Register Issue 1461, eff. 1/21/2022.