| (a) A program provider must maintain a copy of the
following records for each individual:
(1) the birth certificate;
(2) relevant legal documents including documents relating
to guardianship, marital status, custody of a minor, or immigration
status, if any;
(3) the Social Security card;
(4) a current photograph;
(5) immunization records;
(6) height and weight records;
(7) seizure records, if any;
(8) the most recent physician's orders, including treatment
and diet orders;
(9) the most recent nursing care plan, if any;
(10) the most recent laboratory test results, if any;
(11) any significant medical reports, including reports
regarding the most recent chest X-ray, electrocardiogram (EKG), and
electroencephalogram (EEG), if any;
(12) the most recent medical examination results and
a summary of the medical history, including all major surgeries, significant
acute illnesses, and injuries requiring hospitalization or a long
recovery period;
(13) a summary of the medication history for the last
five years or from the time services were initiated, whichever is
most recent, including start and stop dates, dose ranges, effectiveness
and reactions of all long-term medications and antibiotics;
(14) the most recent dental examination results and
a summary of the dental history, including all oral surgeries, extractions,
restorations, appliances, and types of anesthesia required for dental
work;
(15) the social history and the most recent psychological
examination results;
(16) Medicaid and, if applicable, Medicare or third-party
insurance cards;
(17) records necessary to disclose the nature and extent
of services provided to the individual; and
(18) any other records required by this subchapter
or the provider agreement.
(b) A program provider must retain the records described
in subsection (a) of this section until the latest of the following
occurs:
(1) five years elapse from the date the records were
created;
(2) any audit exception or litigation involving the
records is resolved; or
(3) the individual becomes 21 years of age.
(c) A program provider must, upon request, make available
to the department or its designee the records described in subsection
(a) of this section.
|
| Source Note: The provisions of this §261.213 adopted to be effective September 1, 2001, 26 TexReg 5384; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127 |
