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December 2016 Texas Medicaid Provider Procedures Manual

Behavioral Health, Rehabilitation, and Case Management Services Handbook : 6 Physician, Psychologist, and Licensed Psychological Associate (LPA) Providers : 6.9 Pharmacological Management Services : 6.9.3 Documentation Requirements

6.9.3
Documentation of medical necessity for pharmacological management must be dated (month/date/year) and signed by the performing provider and must address all of the following information in the client’s medical record in legible format:
Current psychiatric symptoms and problems, to include presenting mental status or physical symptoms that indicate the client requires a medication adjustment
Current laboratory values, if applicable, for medications requiring monitoring for potential side effects, e.g., hyperglycemia caused by anti-psychotic medications

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