| (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:
(A) legible;
(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
Cont'd... |
