22 Tex. Admin. Code § 76.1 - Required Contents of Patient Records
(a) "Patient record" means any record
regularly used, created, or stored by a licensee or other person pertaining to
a patient's history, diagnosis, treatment, prognosis, or billing, including
records of other health care providers, currently or having been in the
possession or custody of the licensee or other person.
(b) "Initial visit" means a contact with a
new patient, a patient presenting a new condition or illness, or a patient
presenting a recurrence of a previous condition.
(c) A licensee shall ensure a patient record
supports all diagnoses, treatments, services, and billing.
(d) A licensee shall ensure a patient record
is timely created, accurately dated, legible, signed or initialed by the
individual who actually performed the treatment or service, and contains a key
to abbreviations.
(e) As a
minimum, a licensee shall include the following in all patient records created
during an initial visit:
(1) patient history;
(2) description of symptoms or
purpose of the visit;
(3) findings
of examinations, including imaging and laboratory records;
(4) assessment;
(5) diagnosis;
(6) prognosis;
(7) treatment plan, recommendations, and
orders; and
(8) treatment or
service provided and the patient's response.
(f) Other than consultations, reports of
findings, or non-therapeutic contacts with a patient, a licensee shall include
in all records of a subsequent visit:
(1) an
updated history since last visit, if any;
(2) the purpose of visit and changes in
symptoms, if any, since last visit;
(3) an examination of the area involved in
the diagnosis;
(4) an assessment
of any change in the patient's condition since last visit;
(5) the treatment or service provided and the
patient's response; and
(6) change
in treatment plan or planned referrals if indicated.
(g) A licensee shall comply with all state
and federal documentation laws pertaining to health care providers.
Notes
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