Current through Reg. 49, No. 52; December 27, 2024
(a) A limited
services rural hospital (LSRH) shall maintain a medical records system in
accordance with the LSRH's written policies and procedures, which must:
(1) contain procedures for collecting,
processing, maintaining, storing, retrieving, authenticating, and distributing
patient medical records; and
(2)
require the medical records to be:
(B) completely and
accurately documented, dated, and timed;
(C) authenticated by the person responsible
for providing or evaluating the service provided no later than 48 hours after
the patient's discharge;
(D)
systematically organized according to a predetermined and uniform medical
record format;
(E) confidential,
secure, and safely stored; and
(F)
readily accessible, including that all a patient's relevant clinical
information is readily available to physicians or practitioners involved in
that patient's care, and an individual's records are timely retrievable upon
request.
(b) An
LSRH shall designate a member of the LSRH's professional staff who is
responsible for maintaining the records and for ensuring the records comply
with the LSRH's written policies and procedures under subsection (a) of this
section.
(c) An LSRH shall maintain
a uniformly formatted and organized medical record for each patient receiving
health care services at the LSRH. The record shall include the following, as
applicable:
(1) complete patient
identification and social data, as described in Code of Federal Regulations
Title 42 §485.540(a)(4)(i) (relating to Conditions of Participation:
Medical Records);
(2) date, time,
and means of the patient's arrival and discharge;
(3) evidence of properly executed informed
consent forms;
(4) allergies and
untoward reactions to drugs recorded in a prominent and uniform
location;
(5) relevant medical
history;
(6) the patient's advance
directive;
(7) assessment of the
patient's health status and health care needs;
(8) a brief summary of the episode, any care
given to the patient before the patient's arrival to the LSRH, the patient's
disposition, and instructions given to the patient;
(9) a complete detailed description of
treatment and procedures performed in the LSRH;
(10) clinical observations, diagnostic
impression, and consultative findings, including results of:
(A) physical examinations, including vital
signs;
(B) diagnostic and
laboratory tests, including clinical laboratory services; and
(C) treatment provided and procedures
performed;
(11) a
pre-anesthesia evaluation by an individual qualified to administer anesthesia
before and LSRH administers anesthesia to a patient;
(12) pathology report on all tissues removed,
except those exempted by the governing body;
(13) for a patient with a length of stay
greater than eight hours, an evaluation of nutritional needs and evidence of
how the LSRH met the patient's identified needs;
(14) all orders of physicians or another
practitioner, who is practicing within the scope of their license and
education;
(15) all reports of
treatments and medications, including 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;
(16) nursing notes and documentation of
complications;
(17) other relevant
information necessary to monitor the patient's progress, such as temperature
graphics and progress notes describing the patient's response to
treatment;
(18) evidence of the
patient's evaluation by a physician, podiatrist, dentist, or another
practitioner, who is practicing within the scope of their license and
education, before dismissal;
(19)
conclusion at the termination of evaluation and 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;
(20) medical advice given to a patient by
telephone; and
(21) dated
signatures of the physician or other health care professional.
(d) Except when otherwise required
or permitted by law, an LSRH shall maintain the strict confidentiality of
patient record information, including any record that contains clinical,
social, financial, or other data on a patient, and provide safeguards against
loss, tampering, altering, improper destruction, unauthorized use, or
inadvertent disclosure.
(e) An LSRH
shall have written policies and procedures governing the use and removal of
records from the LSRH and the conditions for the release of information. The
written policies and procedures shall include all the following requirements.
(1) An LSRH shall obtain a patient's or their
legally authorized representative's written consent before releasing
information not required by law.
(2) An LSRH shall retain medical records
until at least the 10th anniversary of the last entry date when the patient was
last treated in the LSRH except as required in subparagraphs (A) and (B) of
this paragraph.
(A) If a patient was younger
than 18 years of age when the LSRH last treated the patient, the LSRH shall
retain the patient's medical records until on or after the date of the
patient's 20th birthday or on or after the 10th anniversary of the last entry
date when the LSRH last treated the patient, whichever date is later.
(B) The LSRH shall not destroy medical
records that relate to any matter that is involved in litigation if the LSRH
knows the litigation has not been finally resolved.
(3) If an LSRH plans to close, the LSRH shall
arrange for disposition of the medical records in accordance with applicable
law. The LSRH shall notify HHSC 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.
(f) An LSRH shall provide written
notice to a patient, or a patient's legally authorized representative as
defined in Texas Health and Safety Code §
241.151, that
the LSRH, unless the exception in subsection (e)(2)(B) of this section applies,
may authorize the disposal of medical records relating to the patient on or
after the periods specified in this section.
(1) The LSRH shall provide the notice to the
patient or the patient's legally authorized representative not later than the
date on which the patient who is or will be the subject of a medical record is
treated, except in an emergency treatment situation.
(2) In an emergency treatment situation, the
LSRH shall provide the notice to the patient or the patient's legally
authorized representative as soon as is reasonably practicable following the
emergency treatment situation.
(g) When necessary for ensuring continuity of
care, the LSRH shall transfer summaries or electronic copies of the patient's
record to the physician or practitioner to whom the patient was referred and,
if appropriate, to the facility where future care will be rendered.
(h) When the LSRH utilizes an electronic
medical records system or other electronic administrative system, which is
conformant with the content exchange standard at Code of Federal Regulations
Title 45 §170.205(d)(2) (relating to Content Exchange Standards and
Implementation Specifications for Exchanging Electronic Health Information),
then the LSRH must demonstrate:
(1) the
system's notification capacity is fully operational and the LSRH uses it in
accordance with all state and federal laws and regulations applicable to the
LSRH's exchange of patient health information;
(2) the system sends notifications that must
include at least patient name, treating practitioner name, and sending
institution name;
(3) to the extent
permissible under applicable federal and state law and regulations, and not
inconsistent with the patient's expressed privacy preferences, the system sends
notifications directly, or through an intermediary that facilitates exchange of
health information, at the time of the patient's registration in the LSRH's
emergency department;
(4) to the
extent permissible under applicable federal and state law and regulations, and
not inconsistent with the patient's expressed privacy preferences, the system
sends notifications directly, or through an intermediary that facilitates
exchange of health information, either immediately prior to, or at the time the
patient's discharge or transfer from the LSRH's emergency department;
and
(5) the LSRH has made a
reasonable effort to ensure the system sends the notifications to all
applicable post-acute care services providers and suppliers, as well as to any
of the following practitioners and entities, which need to receive notification
of the patient's status for treatment, care coordination, or quality
improvement purposes:
(A) the patient's
established primary care practitioner;
(B) the patient's established primary care
practice group or entity; or
(C)
other practitioner, or other practice group or entity, identified by the
patient as the practitioner, or practice group or entity, primarily responsible
for their care.
(i) An LSRH shall provide medical records in
the form and format requested by the individual or their legally authorized
representative, if it is readily producible in such form and format. This
includes in an electronic form or format when such medical records are
maintained electronically or if not, in a readable hard copy form or such other
form and format as agreed to by the LSRH and the individual.
(j) An LSRH shall provide records within a
reasonable timeframe. The LSRH must not frustrate the legitimate efforts of
individuals to gain access to their own medical records and must actively seek
to meet these requests as quickly as its record keeping system
permits.
