Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 554 - NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION › Subchapter T - ADMINISTRATION › Section 554.1911 - Contents of the Clinical Record

Current through Reg. 49, No. 28; July 12, 2024
(a) A resident's clinical record must meet
				  all documentation requirements in the HHSC rule at Texas Administrative Code,
				  Title 1, Part 15, Chapter 371, Subchapter C (relating to Utilization Review)
				  .
(b) The clinical record of each
				  resident must contain:
(1) a face sheet that
				  contains the attending physician's current mailing address and telephone
				  numbers;
(2) sufficient information
				  to identify and care for the resident, to include at a minimum:
(A) full name of resident;
(B) full home or mailing address, or
				  both;
(C) social security
				  number;
(D) health insurance claim
				  numbers, if applicable;
(E) date of
				  birth; and
(F) clinical record
				  number, if applicable;
(3) a record of the resident's assessments,
				  including 15 months of MDS records;
(4) the comprehensive care plan and services
				  provided;
(5) a permanency plan,
				  for residents younger than 22 years of age;
(6) the results of any Preadmission Screening
				  and Resident Review;
(7) signed and
				  dated clinical documentation from all health care practitioners involved in the
				  resident's care, with each page identifying the name of the resident for whom
				  the clinical care is intended;
(8)
				  any directives or medical powers of attorney as described in § 554.419 of
				  this chapter (relating to Advance Directives);
(9) discharge information and a discharge
				  summary in accordance with § 554.803 of this chapter (relating to
				  Discharge Summary (Discharge Plan of Care));
(10) at admission or within 14 days after
				  admission, documentation of an initial medical evaluation, including history,
				  physical examination, diagnoses and an estimate of discharge potential and
				  rehabilitation potential, and documentation of a previous annual medical
				  examination;
(11) authentication of
				  a hospital diagnosis, which may be in the form of a signed hospital discharge
				  summary, a signed report from the resident's hospital or attending physician,
				  or a transfer form signed by the physician;
(12) the physician's signed and dated orders,
				  including medication, treatment, diet, restorative and special medical
				  procedures, and routine care to maintain or improve the resident's functional
				  abilities (required for the safety and well-being of the resident), which must
				  not be changed either on a handwritten or computerized physician's order sheet
				  after the orders have been signed by the physician unless space allows for
				  additional orders below the physician's signature, including space for the
				  physician to sign and date again;
(13) arrangements for the emergency care of
				  the resident in accordance with § 554.1204 of this chapter (relating to
				  Availability of Physician for Emergency Care);
(14) observations made by nursing personnel
				  according to the time frames specified in § 554.1010 of this chapter
				  (relating to Nursing Practices);
(15) items as specified on the MDS
				  assessment;
(16) current
				  information, including:
(A) PRN medications
				  and results;
(B) treatments and any
				  notable results;
(C) physical
				  complaints, changes in clinical signs and behavior, mental and behavioral
				  status, and all incidents or accidents;
(D) flow sheets, which may include bathing,
				  restraint observation or release documentation, elimination, fluid intake,
				  vital signs, ambulation status, positioning, continence status and care, and
				  weight;
(E) a record of dietary
				  intake, including deviations from normal diet, rejection of substitutions, and
				  physician's ordered snacks or supplemental feedings;
(F) a record of the date and hour a drug or
				  treatment is administered; and
(G)
				  documentation of a special procedure performed for the safety and well-being of
				  the resident; and
(17)
				  laboratory, radiology and other diagnostic services reports, as required by
				  § 554.1908 of this subchapter (relating to Laboratory Services) and §
				  554.1909 of this subchapter (relating to Radiology and Other Diagnostic
				  Services).