SECTION 414.405. Documentation of Informed Consent

(a) Informed medication consent must be obtained for each individual medication, not by medication class.

(b) Informed consent for the administration of each psychoactive medication will be evidenced by a completed copy of the department's form, Consent to Treatment with Psychoactive Medication (MHRS 9-7 form (or other format including the same information)) executed by the patient or his or her LAR. A copy of which may be obtained by contacting TDMHMR, Office of Policy Development, P.O. Box 12668, Austin, TX 78711-2668.

(1) Any time the medication regimen is altered in a way that would result in a significant change in the risks or benefits for the patient, an explanation of the change will be provided to the patient and the patient's legally authorized representative. The explanation will include notification of the right to withdraw consent at any time.

(2) A new consent will be obtained if a change to a different medication is prescribed.

(c) If the patient or his or her LAR consents to the administration of psychoactive medication but refuses or is unable to execute the form, a witness to the consent will be obtained. The consent and its witnessing will be documented in the patient's medical record or on the MHRS 9-7 form (or other format including the same information) and placed in the medical record. The witness will confirm this consent by signing the consent form.

(d) If the RN, LVN, PA, or RPh gives the initial explanation of the consent information to the patient, then the treating physician must confirm the explanation and the consent and sign the MHRS 9-7 form (or other format including the same information) within two working days, not including weekends or legal holidays.

(e) A patient's refusal or attempt to refuse to receive psychoactive medication, whether given verbally or by other indications or means, will be documented in the progress notes of the patient's clinical record or on the consent form (MHRS 9-7 form (or other format including the same information)).

(f) An LAR's refusal to consent for the patient's treatment will be documented in the patient's medical record.

(g) All consents will be reviewed with the patient and his or her legally authorized representative at least annually. The review will include a discussion of the information outlined in §414.404 of this title (relating to Information Required To Be Given) as well as a discussion of the patient and his or her legally authorized representative's wishes regarding continuation of the medication.

Source Note: The provisions of this §414.405 adopted to be effective August 31, 2004, 29 TexReg 8317