(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.
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