SECTION 76.1. Required Contents of Patient Records

(a) "Patient record" means any record regularly used, created, or stored by a licensee or other person pertaining to a patient's history, diagnosis, treatment, prognosis, or billing, including records of other health care providers, currently or having been in the possession or custody of the licensee or other person.

(b) "Initial visit" means a contact with a new patient, a patient presenting a new condition or illness, or a patient presenting a recurrence of a previous condition.

(c) A licensee shall ensure a patient record supports all diagnoses, treatments, services, and billing.

(d) A licensee shall ensure a patient record is timely created, accurately dated, legible, signed or initialed by the individual who actually performed the treatment or service, and contains a key to abbreviations.

(e) As a minimum, a licensee shall include the following in all patient records created during an initial visit:

(1) patient history;

(2) description of symptoms or purpose of the visit;

(3) findings of examinations, including imaging and laboratory records;

(4) assessment;

(5) diagnosis;

(6) prognosis;

(7) treatment plan, recommendations, and orders; and

(8) treatment or service provided and the patient's response.

(f) Other than consultations, reports of findings, or non-therapeutic contacts with a patient, a licensee shall include in all records of a subsequent visit:

(1) an updated history since last visit, if any;

(2) the purpose of visit and changes in symptoms, if any, since last visit;

(3) an examination of the area involved in the diagnosis;

(4) an assessment of any change in the patient's condition since last visit;

(5) the treatment or service provided and the patient's response; and

(6) change in treatment plan or planned referrals if indicated.

(g) A licensee shall comply with all state and federal documentation laws pertaining to health care providers.

Source Note: The provisions of this §76.1 adopted to be effective September 13, 2020, 45 TexReg 6360