Texas Administrative Code › Title 25 - HEALTH SERVICES › Part 1 - DEPARTMENT OF STATE HEALTH SERVICES › Chapter 137 - BIRTHING CENTERS › Subchapter D - OPERATIONAL AND CLINICAL STANDARDS FOR THE PROVISION AND COORDINATION OF TREATMENT AND SERVICES › Section 137.53 - Clinical Records

Current through Reg. 49, No. 28; July 12, 2024
The center must adopt, implement, enforce and maintain a
					 clinical record system to assure that the care and services provided to each
					 client is completely and accurately documented, and systematically organized to
					 facilitate the compilation and retrieval of information. At the time of an
					 on-site survey, all clinical records shall be readily retrievable for review
					 within two hours of the request.
(1)
				  For each client, a center may keep a single file or separate files for each
				  stage of service provided to the client.
(2) The center shall have written procedures
				  which are adopted, implemented, and enforced regarding the removal of records
				  and the release of information. A center shall not release any portion of a
				  client record to anyone other than the client except as allowed by
				  law.
(3) All information regarding
				  the client's care and services shall be centralized in the client's record and
				  be protected against loss or damage.
(4) The center shall establish an area for
				  client record storage at the center's place of business. The client record
				  shall be stored at the place of business from which services are actually
				  provided.
(5) The center shall
				  ensure that each client's record is treated with confidentiality, safeguarded
				  against loss and unofficial use, and is maintained according to professional
				  standards of practice.
(6) The
				  clinical record shall be an original, a microfilmed copy, an optical disc
				  imaging system, or a certified copy. An original record includes manually
				  signed paper records or electronically signed computer records. Computerized
				  records shall meet all requirements of paper records including protection from
				  unofficial use and retention for the period specified in paragraph (10) of this
				  subsection. Systems shall assure that entries regarding the delivery of care or
				  services may not be altered without evidence and explanation of such
				  alteration.
(7) Each entry to the
				  client record shall be accurate, signed, and dated with the date of entry by
				  the individual making the entry. Correction fluid or tape shall not be used in
				  the record. Corrections shall be made by striking through the error with a
				  single line and shall include the date the correction was made and the initials
				  of the person making the correction.
(8) Inactive client records may be preserved
				  and stored on microfilm, optical disc or other electronic means. Security shall
				  be maintained and records must be readily retrievable by the center within two
				  hours of a request for a record(s) by the department.
(9) The clinical record must contain the
				  following:
(A) client identifying
				  information;
(B) name of the
				  client's birth attendant(s) and the name of all other clinical care
				  providers;
(C) initial risk
				  assessment;
(D) a disclosure
				  statement and informed consent that is signed by a client that explains the
				  benefits, limitations, and risks of the services available to them at the
				  center, and that describes the collaborative arrangements that the center has
				  with physicians and with referral hospitals;
(E) the informed choice agreement required to
				  be given a client by a licensed midwife, if applicable;
(F) record of antepartum (prenatal)
				  care;
(G) history and physical
				  examination of the clients;
(H)
				  laboratory procedures;
(I) progress
				  notes shall be written, signed and dated by the person rendering the service on
				  the day service is rendered and incorporated into the client record on a timely
				  basis;
(J) medication list and
				  medication administration record, if applicable;
(K) intrapartum care;
(L) newborn care;
(M) postpartum care;
(N) allergies and medication
				  reactions;
(O) documentation for
				  consultation;
(P) refusal of the
				  client to comply with advice or treatment;
(Q) discharge summary;
(R) documentation of client transfers or
				  referrals, if applicable; and
(S)
				  documentation that:
(i) a birth certificate
				  was filed; or
(ii) if applicable, a
				  death certificate was filed.