Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 550 - LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS › Subchapter C - GENERAL PROVISIONS › Division 9 - MEDICAL RECORDS, QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT, DISSOLUTION AND RETENTION OF RECORDS › Section 550.1001 - Medical Records

Current through Reg. 49, No. 28; July 12, 2024
(a) In accordance
					 with accepted principles of practice, a center must establish and maintain a
					 medical record system to ensure that the services provided to a minor are
					 completely and accurately documented, readily accessible, and systematically
					 organized to facilitate the compilation and retrieval of information.
(b) A center must establish a record for a
					 minor and must maintain the record in accordance with and contain the
					 information described in subsection (g) of this section.
(c) A center must keep a single file for
					 services provided to a minor and a minor's parent.
(d) A center must adopt and enforce written
					 procedures regarding the use and removal of records, the release of
					 information, and when applicable, the incorporation of clinical, progress, or
					 other notes into the medical record.
(e) A center may not release any portion of a
					 minor's medical record to anyone other than an adult minor and a minor's
					 parent, except as allowed by law.
(f) A center must establish a secure area for
					 original active medical record storage at the center's place of business.
(1) A center must ensure that a minor's
					 medical record is treated as confidential, safeguarded against loss and
					 unofficial use, and maintained according to professional standards of
					 practice.
(2) A center must keep a
					 minor's medical record in original form, as a microfilmed copy, on an
					 electronic system, or as a certified copy.
(3) A medical record in its original form is
					 a signed paper record or an electronically signed computer record.
(4) A center must ensure that computerized
					 medical records meet the requirements of paper records, including protection
					 from unofficial use as specified in subsection (g) of this section and
					 retention for the period specified in § 550.1004 of this division
					 (relating to Retention of Records).
(5) A center must ensure that an entry to a
					 medical record regarding the delivery of services is not altered without
					 evidence and explanation of the alteration.
(6) A center must ensure that an entry to a
					 minor's medical record is current, accurate, legible, clear, complete, and
					 appropriately authenticated and dated with the date of entry by the individual
					 making the entry. The record must document all services provided on behalf of
					 the center. The center must not use correction fluid or tape in the record. The
					 center must make corrections by striking through the error with a single line
					 and including the date the correction was made and the initials of the person
					 making the correction.
(7) A center
					 must store the record of an inactive minor's medical record on paper,
					 microfilm, or electronically. The center must secure the medical record and
					 ensure that it is readily retrievable by the center staff.