Texas Administrative Code
Title 26 - HEALTH AND HUMAN SERVICES
Part 1 - HEALTH AND HUMAN SERVICES COMMISSION
Chapter 306 - BEHAVIORAL HEALTH DELIVERY SYSTEM
Subchapter B - STANDARDS OF CARE IN CRISIS STABILIZATION UNITS
Division 5 - OPERATIONAL REQUIREMENTS
Section 306.81 - Medical Record
Universal Citation: 26 TX Admin Code ยง 306.81
Current through Reg. 49, No. 38; September 20, 2024
(a) A medical record must be maintained for each individual, in accordance with § 510.41(g) of this title (relating to Facility Functions and Services). The medical record must include:
(1) a signed voluntary
commitment, signed order of protective custody or police officer's warrant, or
a notice of detention;
(2) a signed
informed consent to treatment, including medication, or documentation of the
individual's refusal;
(3)
documentation of the reasons the individual, LAR, family members, or other
adult caregivers state the individual was admitted to the CSU;
(4) justification for each mental illness or
serious emotional disturbance diagnosis and any substance use disorder
diagnosis;
(5) the level of
monitoring assigned and implemented for the individual, including any changes
to the level of monitoring;
(6) the
individual's written recovery or treatment plan;
(7) the name of the individual's treating
physician;
(8) written findings of
the physical examination;
(9)
written findings of the psychiatric evaluation, the nursing assessment, and any
other assessment of the individual conducted by a staff member, including any
re-evaluation or re-assessment;
(10) a summary of any revisions made to the
written recovery or treatment plan;
(11) the progress notes for the individual as
described in subsection (b) of this section;
(12) documentation of the individual's
monitoring by UPs, LVNs, and any assigned staff members responsible for such
monitoring, including observations of the individual at pre-determined
intervals;
(13) documentation of
the discharge planning activities;
(14) the discharge summary; and
(15) documentation of the individual's
medical, mental health, and substance use history.
(b) Progress notes are required for each individual. A physician, a physician-delegated PA or APRN, or RN and any assigned staff members providing services to an individual must document the individual's progress and response to treatment provided in the individual's recovery or treatment plan.
Disclaimer: These regulations may not be the most recent version. Texas may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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