26 Tex. Admin. Code § 554.1911 - Contents of the Clinical Record
(a) A
resident's clinical record must meet all documentation requirements in the HHSC
rule at Texas Administrative Code, Title 1, Part 15, Chapter 371, Subchapter C
(relating to Utilization Review).
(b) The clinical record of each resident must
contain:
(1) a face sheet that contains the
attending physician's current mailing address and telephone numbers;
(2) sufficient information to identify and
care for the resident, to include at a minimum:
(A) full name of resident;
(B) full home or mailing address, or
both;
(C) social security
number;
(D) health insurance claim
numbers, if applicable;
(E) date of
birth; and
(F) clinical record
number, if applicable;
(3) a record of the resident's assessments,
including 15 months of MDS records;
(4) the comprehensive care plan and services
provided;
(5) a permanency plan,
for residents younger than 22 years of age;
(6) the results of any Preadmission Screening
and Resident Review;
(7) signed and
dated clinical documentation from all health care practitioners involved in the
resident's care, with each page identifying the name of the resident for whom
the clinical care is intended;
(8)
any directives or medical powers of attorney as described in §
554.419 of this chapter (relating
to Advance Directives);
(9)
discharge information and a discharge summary in accordance with §
554.803 of this chapter (relating
to Discharge Summary (Discharge Plan of Care));
(10) at admission or within 14 days after
admission, documentation of an initial medical evaluation, including history,
physical examination, diagnoses and an estimate of discharge potential and
rehabilitation potential, and documentation of a previous annual medical
examination;
(11) authentication of
a hospital diagnosis, which may be in the form of a signed hospital discharge
summary, a signed report from the resident's hospital or attending physician,
or a transfer form signed by the physician;
(12) the physician's signed and dated orders,
including medication, treatment, diet, restorative and special medical
procedures, and routine care to maintain or improve the resident's functional
abilities (required for the safety and well-being of the resident), which must
not be changed either on a handwritten or computerized physician's order sheet
after the orders have been signed by the physician unless space allows for
additional orders below the physician's signature, including space for the
physician to sign and date again;
(13) arrangements for the emergency care of
the resident in accordance with §
554.1204 of this chapter (relating
to Availability of Physician for Emergency Care);
(14) observations made by nursing personnel
according to the time frames specified in §
554.1010 of this chapter (relating
to Nursing Practices);
(15) items
as specified on the MDS assessment;
(16) current information, including:
(A) PRN medications and results;
(B) treatments and any notable
results;
(C) physical complaints,
changes in clinical signs and behavior, mental and behavioral status, and all
incidents or accidents;
(D) flow
sheets, which may include bathing, restraint observation or release
documentation, elimination, fluid intake, vital signs, ambulation status,
positioning, continence status and care, and weight;
(E) a record of dietary intake, including
deviations from normal diet, rejection of substitutions, and physician's
ordered snacks or supplemental feedings;
(F) a record of the date and hour a drug or
treatment is administered; and
(G)
documentation of a special procedure performed for the safety and well-being of
the resident; and
Notes
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