| (a) In accordance with accepted principles of practice,
a center must establish and maintain a medical record system to ensure
that the services provided to a minor are completely and accurately
documented, readily accessible, and systematically organized to facilitate
the compilation and retrieval of information.
(b) A center must establish a medical record for a
minor and must maintain the record in accordance with and contain
the information described in subsection (g) of this section.
(c) A center must keep a single file for services provided
to a minor and a minor's parent.
(d) A center must adopt and enforce written procedures
regarding the use and removal of records, the release of information,
and when applicable, the incorporation of clinical, progress, or other
notes into the medical record.
(e) A center may not release any portion of a minor's
medical record to anyone other than the adult minor or the minor's
parent, except as allowed by law.
(f) A center must establish a secure area for original
active medical record storage at the center's place of business.
(1) A center must ensure that a minor's medical record
is treated as confidential, safeguarded against loss and unofficial
use, and maintained according to professional standards of practice.
(2) A center must keep a minor's medical record in
original form, as a microfilmed copy, on an electronic system, or
as a certified copy.
(3) A medical record in its original form is a signed
paper record or an electronically signed computer record.
(4) A center must ensure that electronic medical records
meet the requirements of paper records, including protection from
unofficial use as specified in subsection (f)(1) of this section.
(5) A center must ensure that an entry to a medical
record regarding the delivery of services is not altered without evidence
and explanation of the alteration.
(6) A center must ensure that an entry to a minor's
medical record is current, accurate, legible, clear, complete, and
appropriately authenticated and dated with the date of entry by the
individual making the entry. The record must document all services
provided on behalf of the center. The center must not use correction
fluid or tape in the record. The center must make corrections by striking
through the error with a single line and including the date the correction
was made and the initials of the person making the correction.
(7) A center must store the record of an inactive minor's
medical record on paper, microfilm, or electronically. The center
must secure the medical record and ensure that it is readily retrievable
by the center staff.
(g) Each medical record must include the following
information as applicable to the services provided on behalf of a
center:
(1) a minor's referral and application for services
including, but not limited to:
(A) the minor's full name;
(B) the minor's sex and date of birth;
(C) the name, address, and telephone number of the
minor's parent, or others as identified by the minor's parent;
(D) the minor's prescribing physician's name and telephone
numbers, and an emergency contact number; and
(E) the minor's prescribing physician's initial order
for services;
(2) comprehensive assessments, pertinent medical history
including allergies and special precautions, and subsequent assessments;
(3) plans of care, nursing care plans, and other plans
as applicable;
(4) verbal orders of a physician reduced to writing
and signed by the physician in accordance with the center's policy
as required by §550.702 of this subchapter (relating to Receiving
Physician Orders);
(5) documentation of nutritional counseling and special
diets, as appropriate;
(6) clinical and progress notes from all professionals
providing services to the minor;
(7) documentation of all known services and significant
events;
(8) current medication list;
(9) medication administration record, if medication
is administered by center staff;
(10) current immunization record;
(11) written acknowledgment of the adult minor's or
the minor's parent's receipt of written notification of the requirements
of §550.901 of this subchapter (relating to Rights and Responsibilities);
(12) written acknowledgment of the adult minor's or
the minor's parent's receipt of a center's policy relating to the
reporting of abuse, neglect, or exploitation of a minor;
(13) written acknowledgement of the adult minor's or
the minor's parent's receipt of the notice of advance directives;
(14) written acknowledgement of the adult minor's or
the minor's parent's receipt of the center's policies relating to
discipline and guidance;
(15) documentation demonstrating that the adult minor
or the minor's parent have been informed of how to register a complaint
in accordance with §550.901 of this subchapter;
(16) discharge summary, including the reason for discharge
or transfer and a center's documented notice to the adult minor, the
minor's parent, the minor's prescribing physician, and other individuals
as required in §550.608 of this subchapter (relating to Discharge
or Transfer Notification);
(17) services provided to the minor's parent; and
(18) all consent and election forms, as applicable.
(h) A center must ensure that clinical and progress
notes are written the day service is rendered and incorporated into
the medical record no later than two business days after the services
are rendered.
(i) A center must ensure the retention of the medical
record for a minor meets the requirements in §550.1004 of this
division (relating to Retention of Records).
|
| Source Note: The provisions of this §550.1001 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929 |
