22 Tex. Admin. Code § 163.1 - Medical Records
(a) The medical
record must be a complete, contemporaneous, and legible documented account of
each patient encounter by a physician or delegate.
(b) To the extent applicable, a medical
record must include, at a minimum:
(1) a
reason for the encounter, relevant history, physical examination findings
(ensuring any pre-populated fields contain current and accurate patient
information), and any diagnostic test results;
(2) an assessment, clinical impression, and
diagnosis;
(3) a plan for care
(including diagnostics, risk factors, consults, referrals, ancillary services,
discharge plan if appropriate, patient/family education, disclosures, and
follow-up instructions), treatments, and medications (including amount,
frequency, number of refills, and dosage);
(4) late entries, if any, that indicate the
time and date entered, as well as the identity of the person who made the late
entry;
(5) summary or documentation
of communications with the patient;
(6) sufficient documentation of requests for
records from other providers and any records received;
(7) clear identification of any amendment or
correction to the medical record, including the date it was amended or
corrected and the identity of the author of the amendment or correction, with
the original text remaining legible; and
(8) documentation of a review of the
patient's Texas Prescription Monitoring Program (PMP) prescribing
history.
Notes
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No prior version found.