Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 568 - STANDARDS OF CARE AND TREATMENT IN PSYCHIATRIC HOSPITALS › Subchapter F - DOCUMENTATION › Section 568.101 - Content of Medical Record

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Medical record. A hospital shall maintain a medical record for a patient. The
				  medical record shall include, at a minimum:
(1) documentation of whether the patient is a
				  voluntary patient, on emergency detention, or under a court order, including
				  the physician or court order, as appropriate;
(2) any applications for admission, court
				  orders for admission, or notices of detention;
(3) documentation of the reasons the patient,
				  legally authorized representative (LAR), family members, or other caregivers
				  state that the patient was admitted to the hospital;
(4) justification for each mental illness
				  diagnosis and any substance-related or addictive disorder diagnosis;
(5) the level of monitoring assigned and
				  implemented in accordance with § 568.25 of this chapter (relating to
				  Monitoring Upon Admission) and any changes to such level before the
				  implementation of the patient's treatment plan;
(6) the patient's treatment plan;
(7) the name of the patient's treating
				  physician;
(8) the names of the
				  members of the patient's interdisciplinary treatment team (IDT), if required by
				  the patient's length of stay;
(9)
				  written findings of the physical examination described in §
				  568.62(e)(1)(A) or (B) of this chapter (relating to Medical
				  Services);
(10) written findings
				  of:
(A) the psychiatric evaluation described
				  in § 568.62(f) of this chapter; and
(B) the assessments described in §
				  568.63(e) of this chapter (relating to Nursing Services), § 568.64(d) of
				  this chapter (relating to Social Services), § 568.65(b) of this chapter
				  (relating to Therapeutic Activities), and § 568.66(b) of this chapter
				  (relating to Psychological Services); and
(C) any other assessment of the patient
				  conducted by a staff member;
(11) the progress notes for the patient as
				  described in subsection (b) of this section;
(12) documentation of the monitoring of the
				  patient by the staff members responsible for such monitoring, including
				  observations of the patient at pre-determined intervals;
(13) documentation of the discharge planning
				  activities required by § 568.81(a)(3) of this chapter (relating to
				  Discharge Planning);
(14) the
				  discharge summary as required by § 568.81(b) of this chapter;
(15) the estimate of charges required to be
				  made part of the record by Texas Health and Safety Code §
											164.009;
(16) medication consent required by Texas
				  Health and Safety Code §
											576.025;
(17) medication administration records;
				  and
(18) evidence that the patient
				  or LAR received and signed a copy of the patients' rights booklet explaining
				  rights listed in the patient bill of rights, plus that it was explained orally
				  or by other means calculated to communicate these rights to a patient. This is
				  specifically required by Texas Health and Safety Code §
											321.002(g)(2)
				  to be included in the patient's record.