Current through Reg. 50, No. 13; March 28, 2025
(a)
Location of documentation. MH case management services, as well as attempts to
provide MH case management services, as described in this section, must be
documented in the individual's medical record.
(1) For routine case management, the case
manager must document the information required by §
306.263(b)(3) -
(6) of this title (relating to MH Case
Management Services Standards), as well as the steps taken to meet the
individual's goals and needs as required by §
306.263(b)(7) of
this title, in the individual's medical record.
(2) For intensive case management:
(A) the assigned case manager must include
the intensive case management plan required by §
306.263(c)(1) of
this title in the individual's medical record; and
(B) the assigned case manager must document
steps taken to meet the individual's goals and needs as required by §
306.263(c)(7) of
this title in the individual's progress notes.
(b) Assessment and reassessment. As a result
of the face-to-face meetings, assessments, and reassessments required in §
306.263 of this title, the case
manager must document the individual's:
(1)
identified strengths, service needs, and assistance given to address the
identified need; and
(2) specific
goals and actions to be accomplished.
(c) Service documentation. The case manager
must document the following for all services provided:
(1) the event or behavior that occurs while
providing the MH case management service or the reason for this specific
encounter;
(2) the person, persons,
or entity, including other case managers, with whom the encounter or contact
occurred;
(3) the recovery plan
goal(s) that was the focus of the MH case management service, including the
progress or lack of progress in achieving recovery plan goal(s);
(4) the timeline for obtaining the needed
services;
(5) the specific
intervention that is being provided;
(6) the plan to proceed based upon the facts
presented in this encounter or the resolution, if any;
(7) the date the MH case management service
was provided;
(8) the begin and end
time of the MH case management service;
(9) the location where the MH case management
service was provided and whether it was a face-to-face or telephone
contact;
(10) the signature of the
employee providing the MH case management service and their credentials;
and
(11) the timeline for
reevaluating the needed services.
(d) Crisis service documentation. In addition
to the requirements described in subsection (a) of this section, a provider
must document the following for crisis intervention services:
(1) the documentation required by Chapter
301, Subchapter G, specifically §
301.351(e) of
this title (relating to Crisis Services); and
(2) the outcome of the individual's
crisis.
(e) Refusing MH
case management services. If the individual refuses MH case management
services, the case manager must:
(1) document
the reason for the refusal in the progress notes of the individual's medical
record; and
(2) request that the
individual sign a waiver of MH case management services that is filed in the
individual's medical record.
(f) Documentation retention. The provider
must retain documentation in compliance with applicable records retention
requirements in federal and state laws, rules, and regulations.
