Section 354.2657 - Documentation Requirements(a) Mental health targeted case management documentation. Mental health targeted case management services must be documented in the individual's medical record. Case managers are required to maintain a record of every individual receiving mental health targeted case management, including:(1) the name of the individual;(2) the name of the comprehensive provider agency and the name of the assigned case manager;(3) the date, nature, content, and units of each service received and whether goals specified in the recovery/treatment plan have been achieved;(4) whether the individual has declined services in the recovery/treatment plan;(5) the need for, and occurrences of, coordination with other staff members;(6) a timeline for obtaining needed services; and(7) a timeline for reevaluation of the recovery/treatment plan.(b) Service documentation. The case manager must document the following for each service provided: (1) the event or behavior that occurs while providing the service or the reason for the specific encounter;(2) the person, persons, or entity, including other staff members, with whom the encounter or contact occurred;(3) a collateral contact that is directly related to identifying the needs and supports for helping the individual access services and managing the individual's care, including coordination with other staff members;(4) the recovery/treatment plan goal(s) that was the focus of the service, including the progress or lack of progress in achieving recovery plan goal(s);(5) the specific intervention provided;(6) the date the service was provided;(7) the start and end time of the service;(8) the mode of delivery used to provide the service and if provided in person, the location where the service was provided; and(9) the signature of the case manager providing the service, including credentials.(c) Crisis service documentation. In addition to the general documentation requirements described in subsection (b) of this section, a staff member must document the following for crisis intervention services:(1) behavioral description of the presenting problem;(2) lethality (e.g., suicide, violence);(3) the individual's relevant substance use;(4) the individual's relevant trauma, abuse, or neglect;(5) all actions, including rehabilitative interventions and referrals to other agencies, used by the provider of crisis intervention services to address the problems presented;(6) the response of the individual, and if appropriate, the response of the LAR or primary caregiver and family members;(7) the signature of the staff member providing the service and a notation as to whether the staff member is an LPHA or a QMHP-CS;(8) any pertinent event or behavior relating to the individual's treatment which occurs during the provision of the service;(9) follow up activities, which may include referral to another provider; and(10) the outcome of the individual's crisis.(d) Refusing mental health targeted case management services. If the individual refuses mental health targeted case management services, the assigned case manager must:(1) document the individual's stated reason for the refusal in the individual's medical record; and(2) request that the individual sign a waiver of case management services that is filed in the individual's medical record.1 Tex. Admin. Code § 354.2657
Adopted by Texas Register, Volume 43, Number 41, October 12, 2018, TexReg 6823, eff. 10/17/2018; Amended by Texas Register, Volume 48, Number 03, January 20, 2023, TexReg 0211, eff. 1/23/2023