Section 511.67 - Medical Records(a) A limited services rural hospital (LSRH) shall maintain a medical records system in accordance with the LSRH's written policies and procedures, which must: (1) contain procedures for collecting, processing, maintaining, storing, retrieving, authenticating, and distributing patient medical records; and(2) require the medical records to be:(B) completely and accurately documented, dated, and timed;(C) authenticated by the person responsible for providing or evaluating the service provided no later than 48 hours after the patient's discharge;(D) systematically organized according to a predetermined and uniform medical record format;(E) confidential, secure, and safely stored; and(F) readily accessible, including that all a patient's relevant clinical information is readily available to physicians or practitioners involved in that patient's care, and an individual's records are timely retrievable upon request.(b) An LSRH shall designate a member of the LSRH's professional staff who is responsible for maintaining the records and for ensuring the records comply with the LSRH's written policies and procedures under subsection (a) of this section.(c) An LSRH shall maintain a uniformly formatted and organized medical record for each patient receiving health care services at the LSRH. The record shall include the following, as applicable:(1) complete patient identification and social data, as described in Code of Federal Regulations Title 42 §485.540(a)(4)(i) (relating to Conditions of Participation: Medical Records);(2) date, time, and means of the patient's arrival and discharge;(3) evidence of properly executed informed consent forms;(4) allergies and untoward reactions to drugs recorded in a prominent and uniform location;(5) relevant medical history;(6) the patient's advance directive;(7) assessment of the patient's health status and health care needs;(8) a brief summary of the episode, any care given to the patient before the patient's arrival to the LSRH, the patient's disposition, and instructions given to the patient;(9) a complete detailed description of treatment and procedures performed in the LSRH;(10) clinical observations, diagnostic impression, and consultative findings, including results of: (A) physical examinations, including vital signs;(B) diagnostic and laboratory tests, including clinical laboratory services; and(C) treatment provided and procedures performed;(11) a pre-anesthesia evaluation by an individual qualified to administer anesthesia before and LSRH administers anesthesia to a patient;(12) pathology report on all tissues removed, except those exempted by the governing body;(13) for a patient with a length of stay greater than eight hours, an evaluation of nutritional needs and evidence of how the LSRH met the patient's identified needs;(14) all orders of physicians or another practitioner, who is practicing within the scope of their license and education;(15) all reports of treatments and medications, including all medications administered and the drug dose, route of administration, frequency of administration, and quantity of all drugs administered or dispensed to the patient by the facility;(16) nursing notes and documentation of complications;(17) other relevant information necessary to monitor the patient's progress, such as temperature graphics and progress notes describing the patient's response to treatment;(18) evidence of the patient's evaluation by a physician, podiatrist, dentist, or another practitioner, who is practicing within the scope of their license and education, before dismissal;(19) conclusion at the termination of evaluation and treatment, including final disposition, the patient's condition on discharge or transfer, and any instructions given to the patient or family for follow-up care;(20) medical advice given to a patient by telephone; and(21) dated signatures of the physician or other health care professional.(d) Except when otherwise required or permitted by law, an LSRH shall maintain the strict confidentiality of patient record information, including any record that contains clinical, social, financial, or other data on a patient, and provide safeguards against loss, tampering, altering, improper destruction, unauthorized use, or inadvertent disclosure.(e) An LSRH shall have written policies and procedures governing the use and removal of records from the LSRH and the conditions for the release of information. The written policies and procedures shall include all the following requirements. (1) An LSRH shall obtain a patient's or their legally authorized representative's written consent before releasing information not required by law.(2) An LSRH shall retain medical records until at least the 10th anniversary of the last entry date when the patient was last treated in the LSRH except as required in subparagraphs (A) and (B) of this paragraph.(A) If a patient was younger than 18 years of age when the LSRH last treated the patient, the LSRH shall retain the patient's medical records until on or after the date of the patient's 20th birthday or on or after the 10th anniversary of the last entry date when the LSRH last treated the patient, whichever date is later.(B) The LSRH shall not destroy medical records that relate to any matter that is involved in litigation if the LSRH knows the litigation has not been finally resolved.(3) If an LSRH plans to close, the LSRH shall arrange for disposition of the medical records in accordance with applicable law. The LSRH shall notify HHSC at the time of closure of the disposition of the medical records, including where the medical records will be stored and the name, address, and phone number of the custodian of the records.(f) An LSRH shall provide written notice to a patient, or a patient's legally authorized representative as defined in Texas Health and Safety Code § 241.151, that the LSRH, unless the exception in subsection (e)(2)(B) of this section applies, may authorize the disposal of medical records relating to the patient on or after the periods specified in this section. (1) The LSRH shall provide the notice to the patient or the patient's legally authorized representative not later than the date on which the patient who is or will be the subject of a medical record is treated, except in an emergency treatment situation.(2) In an emergency treatment situation, the LSRH shall provide the notice to the patient or the patient's legally authorized representative as soon as is reasonably practicable following the emergency treatment situation.(g) When necessary for ensuring continuity of care, the LSRH shall transfer summaries or electronic copies of the patient's record to the physician or practitioner to whom the patient was referred and, if appropriate, to the facility where future care will be rendered.(h) When the LSRH utilizes an electronic medical records system or other electronic administrative system, which is conformant with the content exchange standard at Code of Federal Regulations Title 45 §170.205(d)(2) (relating to Content Exchange Standards and Implementation Specifications for Exchanging Electronic Health Information), then the LSRH must demonstrate:(1) the system's notification capacity is fully operational and the LSRH uses it in accordance with all state and federal laws and regulations applicable to the LSRH's exchange of patient health information;(2) the system sends notifications that must include at least patient name, treating practitioner name, and sending institution name;(3) to the extent permissible under applicable federal and state law and regulations, and not inconsistent with the patient's expressed privacy preferences, the system sends notifications directly, or through an intermediary that facilitates exchange of health information, at the time of the patient's registration in the LSRH's emergency department;(4) to the extent permissible under applicable federal and state law and regulations, and not inconsistent with the patient's expressed privacy preferences, the system sends notifications directly, or through an intermediary that facilitates exchange of health information, either immediately prior to, or at the time the patient's discharge or transfer from the LSRH's emergency department; and(5) the LSRH has made a reasonable effort to ensure the system sends the notifications to all applicable post-acute care services providers and suppliers, as well as to any of the following practitioners and entities, which need to receive notification of the patient's status for treatment, care coordination, or quality improvement purposes:(A) the patient's established primary care practitioner;(B) the patient's established primary care practice group or entity; or(C) other practitioner, or other practice group or entity, identified by the patient as the practitioner, or practice group or entity, primarily responsible for their care.(i) An LSRH shall provide medical records in the form and format requested by the individual or their legally authorized representative, if it is readily producible in such form and format. This includes in an electronic form or format when such medical records are maintained electronically or if not, in a readable hard copy form or such other form and format as agreed to by the LSRH and the individual.(j) An LSRH shall provide records within a reasonable timeframe. The LSRH must not frustrate the legitimate efforts of individuals to gain access to their own medical records and must actively seek to meet these requests as quickly as its record keeping system permits.26 Tex. Admin. Code § 511.67
Adopted by Texas Register, Volume 48, Number 39, September 29, 2023, TexReg 5682, eff. 10/5/2023