(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 §412.321(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 §416.6 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.

Source Note: The provisions of this §306.323 adopted to be effective January 22, 2014, 39 TexReg 299; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1239