Texas Administrative Code › Title 25 - HEALTH SERVICES › Part 1 - DEPARTMENT OF STATE HEALTH SERVICES › Chapter 117 - END STAGE RENAL DISEASE FACILITIES › Subchapter D - MINIMUM STANDARDS FOR PATIENT CARE AND TREATMENT › Section 117.47 - Clinical Records

Current through Reg. 49, No. 28; July 12, 2024
(a) A facility
				  shall develop, implement, and enforce policies and procedures for a clinical
				  record system to assure that the care provided to each patient is completely
				  and accurately documented, readily available, and systematically organized to
				  facilitate the compilation and retrieval of information.
(1) All information shall be centralized in
				  the patient's clinical record and be protected against loss or damage in
				  accordance with state and federal regulations.
(2) The facility shall provide an area for
				  clinical records storage which is separate from all patient treatment areas,
				  and shall be secured from unauthorized access. The facility shall store the
				  active clinical record of each patient currently treated by the facility on
				  site.
(3) The facility shall ensure
				  that each patient's personal and clinical records are treated with
				  confidentiality.
(4) Signature
				  stamps shall not be used to authenticate clinical record entries.
(5) Clinical records may be preserved
				  electronically. Computerized records shall meet all requirements of paper
				  records, including protection from casual access and retention for the
				  specified period. Systems shall assure that entries regarding the delivery of
				  care may not be altered without evidence and explanation of such
				  alteration.
(6) Inactive clinical
				  records may be preserved on microfilm, optical disc, or other electronic means,
				  and may be stored off site as long as security is maintained and the record is
				  readily retrievable for review by the department or the department's
				  designee.
(7) Each patient's
				  clinical record, whether hard copy, electronic, or a combination of both, shall
				  include complete and pertinent information about the condition of the patient,
				  assessments by the interdisciplinary team, updated plans of care, all
				  interventions and treatments prescribed and delivered, and details of any
				  events occurring with the patient during the course of treatment. The record of
				  care shall be readily accessible to every authorized member of the
				  interdisciplinary team so that safe care can be coordinated to best meet the
				  needs of the patient.
(8) Each
				  clinical record shall include:
(A)
				  identifying information;
(B)
				  consents and notifications;
(C)
				  physician orders;
(D) progress
				  notes;
(E) problem list;
(F) medical history and physical;
(G) professional assessments by the
				  registered nurse, social worker, and dietitian;
(H) medication record to include medications
				  given during treatment (which may be listed on the treatment record) and a
				  listing of medications the patient takes at home;
(I) transfusion record;
(J) laboratory reports;
(K) diagnostic studies;
(L) hospitalization records;
(M) consultations;
(N) record of creation and revision of access
				  for dialysis;
(O) plans of care,
				  including evidence of interdisciplinary team review and adjustment;
(P) evidence of patient education;
(Q) daily treatment records; and
(R) discharge summary, if
				  applicable.