| (a) Medical record. A hospital shall maintain a medical
record for a patient. The medical record shall include, at a minimum:
(1) documentation of whether the patient is a voluntary
patient, on emergency detention, or under a court order, including
the physician or court order, as appropriate;
(2) any applications for admission, court orders for
admission, or notices of detention;
(3) documentation of the reasons the patient, legally
authorized representative (LAR), family members, or other caregivers
state that the patient was admitted to the hospital;
(4) justification for each mental illness diagnosis
and any substance-related or addictive disorder diagnosis;
(5) the level of monitoring assigned and implemented
in accordance with §568.25 of this chapter (relating to Monitoring
Upon Admission) and any changes to such level before the implementation
of the patient's treatment plan;
(6) the patient's treatment plan;
(7) the name of the patient's treating physician;
(8) the names of the members of the patient's interdisciplinary
treatment team (IDT), if required by the patient's length of stay;
(9) written findings of the physical examination described
in §568.62(e)(1)(A) or (B) of this chapter (relating to Medical
Services);
(10) written findings of:
(A) the psychiatric evaluation described in §568.62(f)
of this chapter; and
(B) the assessments described in §568.63(e) of
this chapter (relating to Nursing Services), §568.64(d) of this
chapter (relating to Social Services), §568.65(b) of this chapter
(relating to Therapeutic Activities), and §568.66(b) of this
chapter (relating to Psychological Services); and
(C) any other assessment of the patient conducted by
a staff member;
(11) the progress notes for the patient as described
in subsection (b) of this section;
(12) documentation of the monitoring of the patient
by the staff members responsible for such monitoring, including observations
of the patient at pre-determined intervals;
(13) documentation of the discharge planning activities
required by §568.81(a)(3) of this chapter (relating to Discharge
Planning);
(14) the discharge summary as required by §568.81(b)
of this chapter;
(15) the estimate of charges required to be made part
of the record by Texas Health and Safety Code §164.009;
(16) medication consent required by Texas Health and
Safety Code §576.025;
(17) medication administration records; and
(18) evidence that the patient or LAR received and
signed a copy of the patients' rights booklet explaining rights listed
in the patient bill of rights, plus that it was explained orally or
by other means calculated to communicate these rights to a patient.
This is specifically required by Texas Health and Safety Code §321.002(g)(2)
to be included in the patient's record.
(b) Progress notes. The progress notes referenced in
subsection (a)(11) of this section must be documented in accordance
with this subsection.
(1) The appropriate members of the patient's IDT shall
make written notes of the patient's progress to include, at a minimum:
(A) documentation of the patient's response to treatment
provided under the treatment plan;
(B) documentation of the patient's progress toward
meeting the goals listed in the patient's treatment plan; and
(C) documentation of the findings of any re-evaluation
or reassessment conducted by a staff member.
(2) Requirements regarding the frequency of making
progress notes are as follows:
(A) a physician shall document the findings of a re-evaluation
described in §568.62(g) of this chapter at the time each re-evaluation
is conducted; and
(B) a registered nurse shall document the findings
of a reassessment described in §568.63(f) of this chapter at
the time each reassessment is conducted.
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