CMS-1500 Initiative Medical Narrative Requirements

The Psychology Narrative requires the following information:
Clinical documentation to support psychology care and services must be consistent with MTG General principles and recommendations.

• Rendering Provider's Name

History

• Description of the occupational incident that precipitated onset of related symptoms
• Detailed description of current symptoms and change in symptoms
• Treatment received and results
• History of medications and response
• Current medication(s), as applicable
• Psychosocial History
• Is the patient working? If yes, provide the date(s) the patient:
  • Resumed limited work of any kind
  • Resumed full work

Causal Relationship:

• Was the occurrence described above (or in your previous report) the competent producing cause of the injury or disability (if any) sustained?

Examination

• Mental status exam
• Results of psychological testing, if performed

Assessment

• Current diagnosis(es)
• Assessment of danger to self or others
• Documentation of clinical evaluation and reassessment is ongoing at each treatment session to document individual treatment goals, monitor progress or lack of progress towards goals and impact of treatment.

Treatment Plan/Recommendations:

Include identification of measurable behavioral goals, specific interventions planned, frequency, timeframes, expected outcomes and plan for re-evaluation of treatment.

• In the absence of progress towards goals, the psychologist must re-evaluate the diagnosis and treatment plan, with modification of the treatment plan or discontinuation of treatment and/ or referral as clinically indicated.
• When testing is indicated, documentation of the specific indication/rationale for each psychological test performed.
• Tests must be performed and interpreted in correlation with clinical interview data to monitor a patient's condition and progress.
• Diagnosis and treatment must be based on a correlation of the clinical interview data and testing, if indicated.