Current through Reg. 49, No. 38; September 20, 2024
(a) A licensed
abortion facility shall maintain a daily patient roster of all patients
receiving abortion services. This daily patient roster shall be retained for a
period of five years.
(b) A
licensed abortion facility shall establish and maintain a clinical record for
each patient. A licensed abortion facility shall maintain the record to assure
that the care and services provided to each patient is completely and
accurately documented, and readily and systematically organized to facilitate
the compilation and retrieval of information.
(1) The facility shall have written
procedures which are adopted, implemented, and enforced regarding the removal
of records and the release of information. A facility shall not release any
portion of a patient record to anyone other than the patient except as allowed
by law.
(2) All information
regarding the care and services shall be centralized in the record and be
protected against loss or damage and unofficial use.
(3) The facility shall establish an area for
patient record storage. The patient records shall be retrievable within two
hours by the facility for patients whose date of the last visit is less than
twelve months. For patients whose date of the last visit is greater than twelve
months, records shall be retrievable within ten days.
(4) The facility shall ensure that each
record is treated with confidentiality.
(5) The clinical record shall be an original,
a microfilmed copy, an optical disc imaging system or other electronic means,
or a certified copy. An original record includes manually signed paper records
or electronically signed computer records. Computerized records shall meet all
requirements of paper records including protection from unofficial use and
retention for the period specified in subsection (d) of this section. Systems
shall assure that entries regarding the delivery of care or services are not
altered without evidence and explanation of such alteration.
(6) A facility shall maintain clinical
records in their original state. Each entry shall be accurate, dated with the
date of entry, and signed by the individual making the entry. Correction fluid
or tape shall not be used in the record. Corrections shall be made by striking
through the error with a single line, and shall include the date the correction
was made and the initials of the person making the correction.
(c) The clinical record shall
contain:
(1) patient identifying
information;
(2) name of
physician;
(3) diagnosis;
(4) history and physical;
(5) a preanesthesia evaluation performed by
personnel approved by the facility to provide anesthesia services;
(6) laboratory reports;
(7) report of gross and/or microscopic
examination of tissue obtained during a surgical abortion;
(8) allergies/drug reactions;
(9) physician's orders;
(10) progress notes to include at a minimum
notations of vital signs; signs and symptoms; response to medication(s) and
treatment(s); and any changes in physical or emotional condition(s). These
notations shall be written, dated, and signed by the individual(s) delivering
patient care no later than 10 days from the day the patient is discharged from
the facility;
(11)
education/information and referral notes;
(12) signed patient consent form;
(13) medication administration records.
Notations of all pharmaceutical agents shall include the time and date
administered, the name of the individual administering the agent, and the
signature of the person making the notation if different than the individual
administering the agent;
(14)
condition on discharge;
(15) the
medical examination or written referral, if obtained;
(16) physician documentation of viability or
nonviability of fetus(es) at a gestational age greater than 26 weeks;
(17) for patients receiving moderate
sedation/analgesia or deep sedation/analgesia:
(A) a minimum of blood pressure, pulse, and
respirations shall be obtained and recorded before sedation, during sedation,
during the procedure, during the initial recovery period, and before discharge
from the facility; and
(B) the
patient's blood oxygenation shall be assessed and recorded, a minimum of at the
time of sedation, during the procedure, and after the procedure;
(18) for an abortion performed or
induced because of a medical emergency, a written document executed by the
physician certifying the abortion is necessary due to a medical emergency and
specifying the medical condition requiring the abortion;
(19) for an abortion performed or induced to
preserve the health of the patient, a written document executed by the
physician specifying the medical condition the abortion is asserted to address
and providing the medical rationale for the physician's conclusion that the
abortion is necessary to address the medical condition; and
(20) for an abortion performed or induced for
a reason other than an abortion described by paragraph (19) of this subsection,
a written document executed by the physician specifying that maternal health is
not a purpose of the abortion.
(d) A licensed abortion facility shall retain
clinical records for adults for seven years from the time of discharge and
clinical records for minors for five years past the age the patient reaches
majority.
(e) A licensed abortion
facility may not destroy patient records that relate to any matter that is
involved in litigation if the facility knows the litigation has not been
finally resolved.
(f) If a licensed
abortion facility closes, there shall be an arrangement for the preservation of
inactive records to ensure compliance with this section. The facility shall
send the Texas Health and Human Services Commission written notification of the
reason for closure, the location of the patient records, and the name and
address of the patient record custodian. If a facility closes with an active
patient roster, a copy of the active patient record shall be transferred with
the patient to the receiving facility or other health care facility in order to
assure continuity of care and services to the patient.
