| (H) clinical observations, including the results of
therapy and treatment, all orders, nursing notes, medication records,
vital signs, and other information necessary to monitor the patient's
condition;
(I) reports of procedures, tests, and their results,
including laboratory, pathology, and radiology reports;
(J) results of all consultative evaluations of the
patient and appropriate findings by clinical and other staff involved
in the care of the patient;
(K) discharge summary with outcome of hospitalization,
disposition of care, and provisions for follow-up care; and
(L) final diagnosis with completion of medical records
within 30 calendar days following discharge.
(10) A hospital may not destroy a medical record from
the forensic medical examination of a sexual assault victim until
the 20th anniversary of the date the record was created, in accordance
with HSC, Chapter 241, Subchapter E, §241.1031.
(11) If a patient was less than 18 years of age at
the time he was last treated, the hospital may authorize the disposal
of those medical records relating to the patient on or after the date
of his 20th birthday or on or after the 10th anniversary of the date
on which he was last treated, whichever date is later.
(12) The hospital shall not destroy medical records
that relate to any matter that is involved in litigation if the hospital
knows the litigation has not been finally resolved.
(13) The hospital shall provide written notice to a
patient, or a patient's legally authorized representative, that the
hospital may authorize the disposal of medical records relating to
the patient on or after the periods specified in this section. The
notice shall be provided 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. In an emergency treatment situation,
the notice shall be provided to the patient or the patient's legally
authorized representative as soon as is reasonably practicable following
the emergency treatment situation.
(14) If a licensed hospital should close, the hospital
shall notify the department at the time of closure the disposition
of the medical records, including the location of where the medical
records will be stored and the identity and telephone number of the
custodian of the records.
(k) Medical staff.
(1) The medical staff shall be composed of physicians
and may also be composed of podiatrists, dentists and other practitioners
appointed by the governing body.
(A) The medical staff shall periodically conduct appraisals
of its members according to medical staff bylaws.
(B) The medical staff shall examine credentials of
candidates for medical staff membership and make recommendations to
the governing body on the appointment of the candidate.
(2) The medical staff shall be well-organized and accountable
to the governing body for the quality of the medical care provided
to patients.
(A) The medical staff shall be organized in a manner
approved by the governing body.
(B) If the medical staff has an executive committee,
a majority of the members of the committee shall be doctors of medicine
or osteopathy.
(C) Records of medical staff meetings shall be maintained.
(D) The responsibility for organization and conduct
of the medical staff shall be assigned only to an individual physician.
(E) Each medical staff member shall sign a statement
signifying they will abide by medical staff and hospital policies.
(3) The medical staff shall adopt, implement, and enforce
bylaws, rules, and regulations to carry out its responsibilities.
The bylaws shall:
(A) be approved by the governing body;
(B) include a statement of the duties and privileges
of each category of medical staff (e.g., active, courtesy, consultant);
(C) describe the organization of the medical staff;
(D) describe the qualifications to be met by a candidate
in order for the medical staff to recommend that the candidate be
appointed by the governing body;
(E) include criteria for determining the privileges
to be granted and a procedure for applying the criteria to individuals
requesting privileges;
(F) include a requirement that a physical examination
and medical history be done no more than 30 days before or 24 hours
after an admission for each patient by a physician or other qualified
practitioner who has been granted these privileges by the medical
staff. The medical history and physical examination shall be placed
in the patient's medical record within 24 hours after admission. When
the medical history and physical examination are completed within
the 30 days before admission, an updated examination for any changes
in the patient's condition must be completed and documented in the
patient's medical record within 24 hours after admission; and
(G) include procedures regarding DNR orders issued
in the hospital by an attending physician that comply with Health
and Safety Code, Chapter 166, Subchapter E (relating to Health Care
Facility Do-Not-Resuscitate Orders), including policies and procedures
regarding the rights of a patient and person authorized to make treatment
decisions regarding the patient's DNR status; notice and medical record
requirements for DNR orders and revocations; and actions the attending
physician and hospital must take pursuant to Health and Safety Code §166.206
when the attending physician or hospital and the patient or person
authorized to make treatment decisions regarding the patient's DNR
status are in disagreement about the execution of, or compliance with,
a DNR order. The procedures shall include that:
(i) Except in circumstances described by Health and
Safety Code §166.203(a)(2), a DNR order issued for a patient
is valid only if the patient's attending physician issues the order,
the order is dated, and the order is issued in compliance with:
(I) the written and dated directions of a patient who
was competent at the time the patient wrote the directions;
(II) the oral directions of a competent patient delivered
to or observed by two competent adult witnesses, at least one of whom
must be a person not listed under Health and Safety Code §166.003(2)(E)
or (F);
(III) the directions in an advance directive enforceable
under Health and Safety Code §166.005 or executed in accordance
with Health and Safety Code §§166.032, 166.034, or 166.035;
(IV) the directions of a patient's legal guardian or
agent under a medical power of attorney acting in accordance with
Health and Safety Code, Chapter 166, Subchapter D (relating to Medical
Power of Attorney); or
(V) a treatment decision made in accordance with Health
Safety Code §166.039.
(ii) A DNR order that is not issued in accordance with
Health and Safety Code §166.203(a)(1) is valid only if the patient's
attending physician issues the order, the order is dated, and:
(I) the order is not contrary to the directions of
a patient who was competent at the time the patient conveyed the directions;
(II) in the reasonable medical judgment of the patient's
attending physician, the patient's death is imminent, regardless of
the provision of cardiopulmonary resuscitation; and
(III) in the reasonable medical judgment of the patient's
attending physician, the DNR order is medically appropriate.
(iii) A DNR order takes effect at the time the order
is issued, as provided by Health and Safety Code §166.203(b).
(iv) Before placing in a patient's medical record a
DNR order described by Health and Safety Code §166.203(a)(2),
the physician, physician assistant, nurse, or other person acting
on behalf of the hospital shall:
(I) notify the patient of the order's issuance; or
(II) if the patient is incompetent, make a reasonably
diligent effort to contact or cause to be contacted and inform of
the order's issuance the patient's known agent under a medical power
of attorney or legal guardian or, for a patient who does not have
a known agent under a medical power of attorney or legal guardian,
a person described by Health and Safety Code §166.039(b)(1),
(2), or (3).
(v) A physician providing direct care to a patient
for whom a DNR order is issued shall revoke the patient's DNR order
if the patient or the patient's agent under a medical power of attorney
or the patient's legal guardian if the patient is incompetent:
(I) effectively revokes an advance directive, in accordance
with Health and Safety Code §166.042, for which a DNR order is
issued under Health and Safety Code §166.203(a); or
Cont'd... |
