Current through Reg. 49, No. 38; September 20, 2024
(a) The facility
shall develop and maintain a system for collecting, processing, maintaining,
storing, retrieving, authenticating, and distributing patient medical
records.
(b) The facility shall
establish an individual medical record for each patient.
(c) All clinical information relevant to a
patient shall be readily available to physicians or practitioners involved in
the care of that patient.
(d)
Except when otherwise required or permitted by law, any record that contains
clinical, social, financial, or other data on a patient shall be strictly
confidential and shall be protected from loss, tampering, alteration, improper
destruction, and unauthorized or inadvertent disclosure.
(e) The facility shall designate a person to
be in charge of medical records. The person's responsibilities include:
(1) confidential, secure, and safe storage of
medical records;
(2) timely
retrieval of individual medical records on request;
(3) specific identification of each patient's
medical record;
(4) supervision of
collecting, processing, maintaining, storing, retrieving, and distributing
medical records; and
(5)
maintenance of a predetermined organized medical record format.
(f) The facility shall retain
medical records in their original or legally reproduced form for a period of at
least 10 years. A legally reproduced form is a medical record retained in hard
copy, microform (microfilm or microfiche), or electronic medium. The facility
shall retain films, scans, and other image records for a period of at least
five years.
(1) The facility shall not destroy
medical records that relate to any matter that is involved in litigation if the
facility knows the litigation has not been finally resolved.
(2) For medical records of a patient less
than 18 years of age at the time of last treatment, the facility may dispose of
those medical records after the date of the patient's 20th birthday or after
the 10th anniversary of the date on which the patient was last treated,
whichever date is later, unless the records are related to a matter that is
involved in litigation that the facility knows has not been finally
resolved.
(3) If a facility plans
to close, the facility shall arrange for disposition of the medical records in
accordance with applicable law. The facility shall notify the Texas Health and
Human Services Commission at the time of closure of the disposition of the
medical records, including where the medical records will be stored and the
name, address, and phone number of the custodian of the records.
(g) Except when otherwise required
by law, the content and format of medical records, including the sequence of
information, shall be uniform.
(h)
Medical records shall be available to authorized physicians and practitioners
any time the facility is open to patients.
(i) The facility shall include in patients'
medical records:
(1) complete patient
identification;
(2) date, time, and
means of arrival and discharge;
(3)
allergies and untoward reactions to drugs recorded in a prominent and uniform
location;
(4) all medications
administered and the drug dose, route of administration, frequency of
administration, and quantity of all drugs administered or dispensed to the
patient by the facility and entered on the patient's medical record;
(5) significant medical history of illness
and results of physical examination, including the patient's vital
signs;
(6) a description of any
care given to the patient before the patient's arrival at the
facility;
(7) a complete detailed
description of treatment and procedures performed in the facility;
(8) clinical observations including the
results of treatment, procedures, and tests;
(9) diagnostic impression;
(10) a pre-anesthesia evaluation by an
individual qualified to administer anesthesia when administered;
(11) a pathology report on all tissues
removed, except those exempted by the governing body;
(12) documentation of a properly executed
informed consent when necessary;
(13) for patients with a length of stay
greater than eight hours, an evaluation of nutritional needs and evidence of
how identified needs were met;
(14)
evidence of patient evaluation by a physician, physician assistant, or advanced
practice registered nurse before dismissal; and
(15) conclusion at the termination of
evaluation or treatment, including final disposition, the patient's condition
on discharge or transfer, and any instructions given to the patient or family
for follow-up care.
(j)
Medical advice given to a patient by telephone shall be entered in the
patient's medical record and dated, timed, and authenticated.
(k) Entries in medical records shall be
legible, accurate, complete, dated, timed, and authenticated by the person
responsible for providing or evaluating the service provided no later than 48
hours after discharge.
(l) To
ensure continuity of care, medical records shall be transferred to the
physician, practitioner, or facility to whom the patient was referred, if
applicable.
