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RULE §131.53Medical Records

(a) The facility shall develop and maintain a system for the collection, processing, maintenance, storage, retrieval, authentication, and distribution of patient medical records.

(b) The facility shall establish an individual medical record for each person receiving care.

(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, but are not limited to:

  (1) the confidentiality, security, and safe storage of medical records;

  (2) the timely retrieval of individual medical records upon request;

  (3) the specific identification of each patient's medical record;

  (4) the supervision of the collection, processing, maintenance, storage, retrieval, and distribution of medical records; and

  (5) the 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 ten years. A legally reproduced form is a medical record retained in hard copy, microform (microfilm or microfiche), or electronic medium. Films, scans, and other image records shall be retained 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 department 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 the following 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 preanesthesia evaluation by an individual qualified to administer anesthesia when administered;

  (11) 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 evaluation of the patient by a physician or advanced practice registered nurse before dismissal; and

  (15) conclusion at the termination of evaluation and/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) When necessary for ensuring continuity of care, summaries or photocopies of the patient's record shall be transferred to the physician or practitioner to whom the patient was referred and, if appropriate, to the facility where future care will be rendered.

Source Note: The provisions of this §131.53 adopted to be effective June 1, 2010, 35 TexReg 4400

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