Texas Administrative Code
Title 26 - HEALTH AND HUMAN SERVICES
Part 1 - HEALTH AND HUMAN SERVICES COMMISSION
Chapter 306 - BEHAVIORAL HEALTH DELIVERY SYSTEM
Subchapter F - MENTAL HEALTH AND REHABILITATIVE SERVICES
Section 306.323 - Documentation Requirements
Universal Citation: 26 TX Admin Code ยง 306.323
Current through Reg. 49, No. 38; September 20, 2024
(a) MH rehabilitative services documentation. A rehabilitative services provider must document the following for all MH rehabilitative services:
(1) the name of the individual to whom the
service was provided;
(2) the type
of service provided;
(3) the
specific goal or objective addressed, modality, and method used to provide the
service;
(4) the date the service
was provided;
(5) the begin and end
time of the service;
(6) the
location where the service was provided;
(7) the signature of the staff member
providing the service and a notation of their credential (e.g., a QMHP-CS, a
pharmacist, a CSSP, a CFP, or a peer provider);
(8) any pertinent event or behavior relating
to the individual's treatment which occurs during the provision of the
service;
(9) any pertinent
information required to be documented by the curricula, protocol, or practice
approved by the department; and
(10) the outcome or response, as applicable:
(A) for crisis intervention service, the
outcome of the crisis;
(B) for
psychosocial coordination services, the outcome of the services;
(C) for day programs for acute needs, the
progress or lack of progress in stabilizing the individual's acute psychiatric
symptoms; or
(D) for all other
services, the individual's response, including the progress or lack of progress
in achieving recovery plan goals and objectives.
(b) Crisis services documentation. In addition to the requirements described in subsection (a) of this section, when providing crisis services, a provider must document the information required by § 301.351(e) of this title (relating to Crisis Services).
(c) Medical necessity documentation. An LPHA must document that MH rehabilitative services are medically necessary when the services are authorized and reauthorized.
(d) Frequency of documentation.
(1) Day programs for acute
needs. For day programs for acute needs, the documentation required by
subsection (a)(1) - (9) and (10)(C) of this section must be made
daily.
(2) Programs other than day
programs for acute needs. For MH rehabilitative services other than day
programs for acute needs, the documentation required by subsection (a)(1) - (9)
and (10)(A), (B), and (D) of this section must be made after each face-to-face
contact that occurs to provide the MH rehabilitative service.
(3) Medical necessity. An LPHA must document
medical necessity in accordance with §
306.311 of this title (relating to
Service Authorization and Recovery Plan).
(4) Retention. A provider must retain
documentation in compliance with applicable federal and state laws, rules, and
regulations.
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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