Texas Administrative Code
Title 22 - EXAMINING BOARDS
Part 3 - TEXAS BOARD OF CHIROPRACTIC EXAMINERS
Chapter 76 - PATIENT RECORDS AND DOCUMENTATION
Section 76.1 - Required Contents of Patient Records

Universal Citation: 22 TX Admin Code ยง 76.1

Current through Reg. 49, No. 38; September 20, 2024

(a) "Patient record" means any record regularly used, created, or stored by a licensee or other person pertaining to a patient's history, diagnosis, treatment, prognosis, or billing, including records of other health care providers, currently or having been in the possession or custody of the licensee or other person.

(b) "Initial visit" means a contact with a new patient, a patient presenting a new condition or illness, or a patient presenting a recurrence of a previous condition.

(c) A licensee shall ensure a patient record supports all diagnoses, treatments, services, and billing.

(d) A licensee shall ensure a patient record is timely created, accurately dated, legible, signed or initialed by the individual who actually performed the treatment or service, and contains a key to abbreviations.

(e) As a minimum, a licensee shall include the following in all patient records created during an initial visit:

(1) patient history;

(2) description of symptoms or purpose of the visit;

(3) findings of examinations, including imaging and laboratory records;

(4) assessment;

(5) diagnosis;

(6) prognosis;

(7) treatment plan, recommendations, and orders; and

(8) treatment or service provided and the patient's response.

(f) Other than consultations, reports of findings, or non-therapeutic contacts with a patient, a licensee shall include in all records of a subsequent visit:

(1) an updated history since last visit, if any;

(2) the purpose of visit and changes in symptoms, if any, since last visit;

(3) an examination of the area involved in the diagnosis;

(4) an assessment of any change in the patient's condition since last visit;

(5) the treatment or service provided and the patient's response; and

(6) change in treatment plan or planned referrals if indicated.

(g) A licensee shall comply with all state and federal documentation laws pertaining to health care providers.

Disclaimer: These regulations may not be the most recent version. Texas may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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