26 Tex. Admin. Code § 554.1910 - Clinical Records
(a) The facility
must maintain clinical records on each resident, in accordance with accepted
professional health information management standards and practices, that are:
(1) complete;
(2) accurately documented;
(3) readily accessible;
(4) systematically organized; and
(5) protected from unauthorized
release.
(b) Clinical
records must be retained :
(1) for five years
after medical services end; or
(2)
for a minor, for three years after a resident reaches legal age under Texas
law.
(c) The facility
must safeguard clinical record information against loss, destruction, or
unauthorized use.
(d) The facility
must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release
is:
(1) required by law or this
chapter;
(2) to the resident or
resident representative where permitted by applicable law;
(3) for treatment, payment, or health care
operations, as permitted by and in compliance with applicable law; or
(4) for public health activities, reporting
of abuse, neglect or domestic violence, health oversight activities, judicial
and administrative proceedings, law enforcement purposes, organ donation
purposes, research purposes, or to coroners, medical examiners, funeral
directors, and to avert a serious threat to health or safety as permitted by
and in compliance with applicable law.
Notes
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