Section 183.10 - Patient Records(a) Acupuncturists licensed under the Act shall keep and maintain adequate records of all patient visits or consultations which shall, at a minimum, be written in English and include: (1) the patient's name and address;(2) vital signs to include body temperature, pulse or heart rate, respiratory rate, and blood pressure upon initial presentation of the patient, and those vital signs as deemed appropriate by the practitioner for follow-up treatment;(3) the chief complaint of the patient;(5) a treatment plan for each patient visit or consultation;(6) a notation of any herbal medications, including amounts and forms, and other modalities used in the course of treatment with corresponding dates for such treatment;(7) a system of billing records which accurately reflect patient names, services rendered, the date of the services rendered, and the amount charged or billed for each service rendered;(8) a written record regarding whether or not a patient was evaluated by a physician or dentist, as appropriate, for the condition being treated within 12 months before the date acupuncture was performed as required by § 183.7(a) of this title (relating to Scope of Practice);(9) a written record regarding whether or not a patient was referred to a physician after the acupuncturist performed acupuncture 20 times or for two months whichever occurs first, as required by § 183.7(b) of this title (relating to Scope of Practice) in regard to treatment of patients upon referral by a doctor licensed to practice chiropractic by the Texas Board of Chiropractic Examiners;(10) in the case of referrals to the acupuncturist of a patient by a doctor licensed to practice chiropractic by the Texas Board of Chiropractic Examiners, the acupuncturist shall record the date of the referral and the most recent date of chiropractic treatment prior to acupuncture treatment; and,(11) reasonable documentation that the evaluation required by § 183.7 of this title (relating to Scope of Practice) was performed or, in the event that the licensee is unable to determine that the evaluation took place, a written statement signed by the patient stating that the patient has been evaluated by a physician within the required time frame on a copy of the following form: Attached Graphic
Attached Graphic
(b) Pursuant to § 205.302 of the Act, an acupuncturist shall not be required to keep and maintain the documentation set forth in subsection (a)(11) of this section when performing acupuncture on a patient only for smoking addiction, substance abuse, alcoholism, chronic pain, or weight loss.(c) Maintenance of Medical and Billing Records.(1) A licensed acupuncturist shall maintain adequate medical and billing records of a patient for a minimum of five years from the anniversary date of the date of last treatment by the acupuncturist.(2) If a patient was younger than 18 years of age when last treated by the acupuncturist, the medical and billing records of the patient shall be maintained by the acupuncturist until the patient reaches age 21 or for five years from the date of last treatment, whichever is longer.(3) Acupuncturists shall retain medical and billing records for such longer length of time than that imposed herein when mandated by other federal or state statute or regulation.(4) An acupuncturist may destroy medical and billing records that relate to any civil, criminal or administrative proceeding only if the physician knows the proceeding has been finally resolved and the records have been maintained at least as long as required by paragraphs (1) - (3) of this subsection.(d) Consent for the release of confidential information must be in writing and signed by the patient, or a parent or legal guardian if the patient is a minor, or a legal guardian if the patient has been adjudicated incompetent to manage his or her personal affairs, or an attorney ad litem appointed for the patient, as authorized by the Texas Mental Health Code Subtitle C, Title 7, Health and Safety Code; the Persons with Mental Retardation Act, Subtitle D, Title 7, Health and Safety Code; Chapter 452, Health and Safety Code, (relating to Treatment of Chemically Dependent Persons); Chapter 5, Texas Probate Code; and Chapter 11, Family Code; or a personal representative if the patient is deceased, provided that the written consent specifies the following: (1) the information or records to be covered by the release;(2) the reason or purposes for the release; and(3) the person to whom the information is to be released.(e) The patient, or other person authorized to consent, has the right to withdraw his or her consent to the release of any information. Withdrawal of consent does not affect any information disclosed prior to the written notice of the withdrawal.(f) Any person who receives information made confidential by this act may disclose the information to others only to the extent consistent with the authorized purposes for which consent to release the information was obtained.(g) An acupuncturist shall furnish legible copies of patient records requested, or a summary or narrative of the records in English, pursuant to a written consent for release of the information as provided by subsection (d) of this section, except if the acupuncturist determines that access to the information would be harmful to the physical, mental, or emotional health of the patient. The acupuncturist may delete confidential information about another person who has not consented to the release. The information shall be furnished by the acupuncturist within 30 days after the date of receipt of the request. Reasonable fees for furnishing the information shall be paid by the patient or someone on his or her behalf. If the acupuncturist denies the request, in whole or in part, the acupuncturist shall furnish the patient a written statement, signed and dated, stating the reason for denial. A copy of the statement denying the request shall be placed in the patient's records. In this subsection, "patient records" means any records pertaining to the history, diagnosis, treatment, or prognosis of the patient.22 Tex. Admin. Code § 183.10
The provisions of this §183.10 adopted to be effective March 6, 2003, 28 TexReg 1883; amended to be effective September 14, 2003, 28 TexReg 7704; amended to be effective May 6, 2009, 34 TexReg 2675