(a) A program provider must maintain a copy of the following records for each individual:
  (1) the birth certificate;
  (2) relevant legal documents including documents relating to guardianship, marital status, custody of a minor, or immigration status, if any;
  (3) the Social Security card;
  (4) a current photograph;
  (5) immunization records;
  (6) height and weight records;
  (7) seizure records, if any;
  (8) the most recent physician's orders, including treatment and diet orders;
  (9) the most recent nursing care plan, if any;
  (10) the most recent laboratory test results, if any;
  (11) any significant medical reports, including reports regarding the most recent chest X-ray, electrocardiogram (EKG), and electroencephalogram (EEG), if any;
  (12) the most recent medical examination results and a summary of the medical history, including all major surgeries, significant acute illnesses, and injuries requiring hospitalization or a long recovery period;
  (13) a summary of the medication history for the last five years or from the time services were initiated, whichever is most recent, including start and stop dates, dose ranges, effectiveness and reactions of all long-term medications and antibiotics;
  (14) the most recent dental examination results and a summary of the dental history, including all oral surgeries, extractions, restorations, appliances, and types of anesthesia required for dental work;
  (15) the social history and the most recent psychological examination results;
  (16) Medicaid and, if applicable, Medicare or third-party insurance cards;
  (17) records necessary to disclose the nature and extent of services provided to the individual; and
  (18) any other records required by this subchapter or the provider agreement.
(b) A program provider must retain the records described in subsection (a) of this section until the latest of the following occurs:
  (1) five years elapse from the date the records were created;
  (2) any audit exception or litigation involving the records is resolved; or
  (3) the individual becomes 21 years of age.
(c) A program provider must, upon request, make available to the department or its designee the records described in subsection (a) of this section.

Source Note: The provisions of this §261.213 adopted to be effective September 1, 2001, 26 TexReg 5384; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127