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7.11.2 Documentation Requirements
The treating provider must document the medical necessity of the chosen treatment and list the DSM-IV-TR diagnosis code that most accurately describes the condition of the client that necessitated the need for the psychological/neuropsychological testing in the client's medical record. The medical record (inpatient or outpatient hospital records, reports, or progress notes) must be signed and dated by the performing provider, and should be clear and concise, documenting the reasons for the psychological/neuropsychological testing and the outcome.
In addition, the following documentation must be maintained by the provider in the client's medical record:
• The Psychological/Neuropsychological Testing Request Form
•The name of the tests that were performed (e.g., Wechsler Adult Intelligence Scale-Revised [WAIS-R], Rorschach, Minnesota Multiphasic Personality Inventory [MMPI])
•How the tests were scored
•The location at which the test was performed
•The name and credentials of each of the providers who were involved in the administration, interpretation, and preparation of the test
•The interpretation of the test, which must include narrative descriptions of the findings of the tests
•The length of time that each provider spent in face-to-face administration, interpretation, reporting the test, integrating the test interpretation, and writing the comprehensive report based on the integrated data
•The treatment being administered, including how the test results affect the prescribed treatment
•Any recommendation for further testing, including an explanation that substantiates its necessity
•An explanation of any rationale or extenuating circumstance that kept the test from being completed, including, but not limited to, situations in which the client's condition required testing over a two-day period and the client did not return or the client's condition precluded the completion of the test
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