SECTION 568.101. Content of Medical Record

(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.

(b) Progress notes. The progress notes referenced in subsection (a)(11) of this section must be documented in accordance with this subsection.

(1) The appropriate members of the patient's IDT shall make written notes of the patient's progress to include, at a minimum:

(A) documentation of the patient's response to treatment provided under the treatment plan;

(B) documentation of the patient's progress toward meeting the goals listed in the patient's treatment plan; and

(C) documentation of the findings of any re-evaluation or reassessment conducted by a staff member.

(2) Requirements regarding the frequency of making progress notes are as follows:

(A) a physician shall document the findings of a re-evaluation described in §568.62(g) of this chapter at the time each re-evaluation is conducted; and

(B) a registered nurse shall document the findings of a reassessment described in §568.63(f) of this chapter at the time each reassessment is conducted.

Source Note: The provisions of this §568.101 adopted to be effective May 27, 2021, 46 TexReg 3276