| (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.
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