|(a) Target signs and symptoms. The prescribing professional will identify and document the target signs and symptoms along with their initial frequency and severity for each medication prescribed prior to its initial use. (b) Choice of psychoactive medication. The prescribing professional will choose the psychoactive medication in accordance with accepted guidelines. (c) Laboratory and screenings. The prescribing professional will identify, order, and follow up any laboratory tests, screenings, or other procedures indicated by the proposed psychoactive medication and the physical condition of the patient in accordance with accepted guidelines. (d) Dose and route of administration. The prescribing professional will choose doses at or below the maximum doses indicated in the TDMHMR Formulary. Higher doses or unusual routes of administration may be used with documentation in the patient record of appropriate supporting clinical rationale. The use of nasogastric intubation requires consultation with a second physician with documentation of the consultation in the supporting clinical rationale. (e) Polypharmacy. The prescribing professional will not prescribe polypharmacy as a mechanism to avoid single drug dosage recommendations, adequate monotherapy drug trials, or adequate psychosocial treatment or programming. Polypharmacy is acceptable practice when: (1) overlapping medications are used as part of a change from one medication to another; (2) currently prescribed medication is not available in the route most appropriate to a psychiatric emergency situation; (3) documentation exists of inadequate patient response after simpler and safer regimens have been attempted following accepted guidelines; or (4) accepted guidelines provide no guidance and appropriate single drug trials have failed, provided the rationale for determining the choice to prescribe polypharmacy is documented to support the situation, and: (A) the prescribing professional is privileged through the medical staff privileging process to prescribe psychoactive medication; and (B) the prescribing professional is a psychiatrist, or in the case of a child patient, a child psychiatrist, or consults with a psychiatrist or a child psychiatrist as appropriate prior to initiating polypharmacy. (f) Orders not written in person. The service setting will have policies and procedures which govern orders not written in person (such as verbal, telephone, fax, or electronic orders) by the prescribing professional. These will address who may give orders, who may accept them, and how orders will be documented in the patient record. Orders will be authenticated by the prescribing professional within a time frame appropriate to the service setting as set forth in that setting's approved policies and procedures. (g) PRN orders. The prescribing professional may write PRN orders in accordance with accepted guidelines and Chapter 414, Subchapter I of this title (relating to Consent to Treatment with Psychoactive Medication-Mental Health Services). The service setting will have policies and procedures for PRN orders that address: (1) indications; (2) appropriate medication classes and dosing, including maximum dose in 24 hours; and (3) time frames for: (A) medication administration; (B) order duration; (C) assessment of effectiveness; (D) continued PRN use; and (E) documentation standards that apply to the order itself and the assessments. (h) Psychiatric emergency orders. The physician may order a single, immediate administration of a psychoactive medication(s) for a psychiatric emergency. The service setting will have policies and procedures for emergency use of psychoactive medications in accordance with accepted guidelines and Chapter 414, Subchapter I of this title, governing Consent to Treatment with Psychoactive Medication-Mental Health Services, and Chapter 412, Subchapter H, governing Standards and Quality Assurance for Mental Retardation Community Services and Supports as appropriate that address: (1) indications; (2) appropriate medication classes and dosing, including maximum dose in 24 hours; (3) assessment of effectiveness; (4) patient education; (5) review with consideration of changing the current plan of care if a pattern of use of psychiatric emergency orders emerges; and (6) documentation time frames and standards that address the incident, the use of medications, and the outcome.