SECTION 301.361. Documentation of Service Provision

(a) Progress note content. Except for crisis services as described in §412.321 of this title (relating to Crisis Services) and day programs for acute needs as described in Chapter 419, Subchapter L of this title (relating to Mental Health Rehabilitative Services), and case management services as described in Chapter 412, Subchapter I of this title (relating to Mental Health Case Management Services), a provider must document the provision of all other mental health community services, each service encounter and include at least the following:

(1) the name of the individual to whom the service was provided, including the LAR or primary caregiver, if applicable;

(2) the type of service provided;

(3) the date the service was provided;

(4) the begin and end time of the service;

(5) the location where the service was provided;

(6) a summary of the activities that occurred;

(7) the modality of the service provision (e.g., individual, group);

(8) the method of service provision (e.g., face-to-face, phone, telemedicine);

(9) the training methods used, if applicable (e.g., instructions, modeling, role play, feedback, repetition);

(10) the title of the curriculum being used, if applicable;

(11) the treatment plan objective(s) that was the focus of the service;

(12) the progress or lack of progress in achieving treatment plan goals;

(13) the signature of the staff member providing the service and a notation as to whether the staff member is an LPHA, a QMHP-CS, a pharmacist, a CSSP, an LVN, a peer provider or otherwise credentialed, as required for that service; and

(14) any pertinent event or behavior relating to the individual's treatment which occurs during the provision of the service.

(b) Frequency of documentation. The documentation required in subsection (a) of this section must be made within two business days after each contact that occurs to provide mental health community services.

(c) Retention. Documentation must be retained in compliance with applicable federal and state laws, rules, and regulations.

Source Note: The provisions of this §301.361 adopted to be effective April 29, 2009, 34 TexReg 2603; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1237