Section 135.9 - Medical Records(a) The ambulatory surgical center (ASC) shall develop and maintain a system for the collection, processing, maintenance, storage, retrieval, and distribution of patient's medical records.(b) An individual medical record shall be established for each person receiving care.(c) All clinical information relevant to a patient shall be readily available to health care practitioners involved in the care of that patient.(d) Except when otherwise required by law, any record that contains clinical, social, financial, or other data on a patient shall be strictly confidential and shall be protected from loss, tampering, alteration, destruction, and unauthorized or inadvertent disclosure.(e) A person shall be designated to be in charge of medical records whose responsibilities include, but are not limited to: (1) the confidentiality, security, and safe storage of medical records;(2) the timely retrieval of individual medical records upon request;(3) the specific identification of each patient's medical record;(4) the supervision of the collection, processing, maintenance, storage, retrieval, and distribution of medical records; and(5) the maintenance of a predetermined organized medical record format.(f) Policies concerning medical records shall follow current statute in regard to retention of active records, retirement of inactive records, and the release of information contained in the record.(g) Except when otherwise required by law, the content and format of medical records, including the sequence of information, shall be uniform.(h) Reports, histories and physicals, progress notes, and other patient information (such as laboratory reports, X-ray readings, and consultation) shall be incorporated into the medical record in a timely manner.(i) Medical records shall be available to authorized health care practitioners any time the ASC is open to patients.(j) The ASC shall include the following in patients' medical records: (1) patient identification;(2) allergies and untoward reactions to drugs recorded in a prominent and uniform location;(3) all preoperative, postoperative medications administered and drug/dose/route/frequency/quantity of all postoperative drugs dispensed to the patient by the ASC and entered on the patient's record;(4) significant medical history and results of physical examination;(5) a preanesthesia evaluation by an individual qualified to administer anesthesia;(6) preoperative diagnostic studies entered before surgery, if required by policy or ordered by a physician, podiatrist, dentist, or advanced practice registered nurse;(7) findings and techniques of the operation (operative report);(8) pathology report on all tissues removed during surgery, except those exempted by the governing body;(9) anesthesia administration record;(10) documentation of a properly executed informed consent;(11) evidence of evaluation of the patient by a physician or advanced practice registered nurse prior to dismissal;(12) evidence that the patient left the facility in the company of a responsible adult, unless the operating surgeon or advanced practice registered nurse writes an order that the patient may leave the facility without the company of a responsible adult; and(13) for patients with a length of stay greater than eight hours, an evaluation of nutritional needs and evidence of how identified needs were met.(k) Appropriate medical advice given to a patient by telephone shall be entered in the patient's medical record and appropriately signed or initialed.(l) Entries in patients' medical records shall be legible to clinical personnel, and shall be accurate and completed promptly.(m) Any notation in a patient's medical record indicating diagnostic or therapeutic intervention as part of clinical research shall be clearly contrasted with entries regarding the provision of nonresearch-related care.(n) When necessary for assuring continuity of care, summaries of records of a patient who was treated elsewhere (such as by another physician, hospital, ambulatory surgical center, nursing home, or consultant) shall be obtained.(o) When necessary for assuring continuity of care, summaries or photocopies of the patient's record shall be transferred to the health care practitioner to whom the patient was referred and, if appropriate, to the facility where future care will be rendered.(p) Certain repetitive procedures are suitable for pre-printed operative notes. These operative notes are suitable as long as they are approved by the governing body, are signed by the surgeon, and transmit to a knowledgeable reader the events of the surgical procedure.(q) All final tissue and abnormal cytology reports from the Medicare-approved reference laboratory shall be signed by a pathologist.25 Tex. Admin. Code § 135.9
The provisions of this §135.9 adopted to be effective June 18, 2009, 34 TexReg 3948