Section 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: (2) description of symptoms or purpose of the visit; (3) findings of examinations, including imaging and laboratory records; (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.22 Tex. Admin. Code § 76.1
Former section transferred to 22 TAC § 72.20 by Texas Register, Volume 43, Number 42, October 19, 2018, TexReg 6963, eff. 11/1/2018; current section adopted by Texas Register, Volume 40, Number 04, January 23, 2015, TexReg 379, eff. 1/29/2015; Adopted by Texas Register, Volume 40, Number 47, November 20, 2015, TexReg 8213, eff. 11/25/2015; Amended by Texas Register, Volume 43, Number 12, March 23, 2018, TexReg 1858, eff. 3/29/2018; Transferred from 22 TAC § 77.7 by Texas Register, Volume 43, Number 42, October 19, 2018, TexReg 6963, eff. 11/1/2018; Adopted by Texas Register, Volume 45, Number 37, September 11, 2020, TexReg 6360, eff. 9/13/2020