SECTION 415.6. Evaluation and Diagnosis

(a) Prior to initiating psychoactive medication according to accepted guidelines, the prescribing professional will:

(1) assess and document the medical history including the chief complaint, psychiatric history, substance use history, and medication history along with medication allergies of the patient;

(2) conduct and document a mental status examination of the patient according to accepted guidelines;

(3) assess and document the current physical status and general health of the patient in detail sufficient for safe prescription of the medication contemplated and may include a reference to a physical examination conducted within the past 12 months, a physical examination by the physician, or a referral of the patient for a more thorough examination as appropriate to health status and service setting;

(4) assess and document the need for laboratory screening and other procedures to gather relevant clinical information; and

(5) make and document the psychiatric diagnosis in accordance with the DSM and within the scope of the professional's license.

(b) The prescribing professional will solicit input and discuss with the team the the proposed treatment with psychoactive medication.

(c) If psychoactive medication known to cause movement disorders is contemplated, an appropriately trained and competent staff will screen the patient for abnormal involuntary movements using a standardized procedure such as the Abnormal Involuntary Movement Scale (AIMS) or Dyskensia Identification System Condensed User Scale (DISCUS), as appropriate, and document the result of the examination prior to initiation of the medication.

(d) In a psychiatric emergency, the assessments and documentation required by this section will take place as soon as is feasible after the emergency. If the patient has already received such assessments during this treatment episode, then the prescribing professional will document only those assessments and decisions that directly relate to the emergency.

Source Note: The provisions of this §415.6 adopted to be effective August 31, 2004, 29 TexReg 8325