SECTION 554.1910. Clinical Records

(a) The facility must maintain clinical records on each resident, in accordance with accepted professional health information management standards and practices, that are:

(1) complete;

(2) accurately documented;

(3) readily accessible;

(4) systematically organized; and

(5) protected from unauthorized release.

(b) Clinical records must be retained:

(1) for five years after medical services end; or

(2) for a minor, for three years after a resident reaches legal age under Texas law.

(c) The facility must safeguard clinical record information against loss, destruction, or unauthorized use.

(d) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is:

(1) required by law or this chapter;

(2) to the resident or resident representative where permitted by applicable law;

(3) for treatment, payment, or health care operations, as permitted by and in compliance with applicable law; or

(4) for public health activities, reporting of abuse, neglect or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with applicable law.

Source Note: The provisions of this §554.1910 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871