(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 §412.407(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 §412.407(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 §412.407(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 §412.407(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 §412.407 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 412, Subchapter G, specifically §412.321(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.

Source Note: The provisions of this §306.275 adopted to be effective February 14, 2013, 38 TexReg 647; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 469