130. Mass. Code Regs. 433.409. - Recordkeeping (Medical Records) Requirements

Payment for any service under Medicare or Medicaid or other medical assistance program is conditioned upon full and complete documentation in the patient’s medical record.  Complete documentation in a medical record means that the record must state the nature, extent, quality and necessity of the treatment provided.  

A medical record that corresponds to a hospital visit, nursing home or emergency room visit must include the reason for the visit and the data upon which treatment or diagnosis was based.  More specifically these medical records must include:

1. patient’s name and date of birth;
2. date of each service;
3. name and title of person performing the service;
4. patient’s medical history;
5. chief complaint;
6. clear indication of findings;
7. medications prescribed;
8. description of treatment given;
9. additional treatments recommended;
10. medical goods dispensed;
11. tests administered and results;