(a) The facility shall maintain for each resident admitted, a separate record with all entries kept current, dated and signed by the recorder. The record shall be accurately written, promptly completed, properly stored and filed, and accessible. At a minimum, the record shall include:
  (1) identification data. The facility shall secure at the time of admission appropriate identifying information, including full name; sex; date of birth; usual occupation; social security number; family/friend name, address, and telephone number; and physician names and telephone numbers including emergency numbers;
  (2) medical history and physical exam reports, if available;
  (3) any physician orders and progress notes, if available;
  (4) any documentation of the resident's change in health condition requiring emergency procedures, and health services provided by facility personnel;
  (5) other documents or reports related to the care of the resident as required by facility policy;
  (6) if appropriate, documentation of nursing services provided and nursing staff observation as required by facility policy; and
  (7) a list of medications the resident is taking.
(b) The facility director shall be responsible for the organization and management of the resident file.
(c) The facility will protect the resident file against loss, damage, destruction, and unauthorized use by:
  (1) safeguarding the confidentiality of the resident file and allowing access or release only as specifically allowed by federal or state laws;
  (2) maintaining files in an organized manner and filing them using an organized system;
  (3) recording entries in ink, computer, or typewritten format and keeping original reports and records; and
  (4) storing files in a lockable area during non-use and after resident's discharge.
(d) Resident files must be retained for at least five years after services end. In the case of a minor, the resident file must be retained for at least three years after the minor reaches majority under state law.
(e) The facility may not destroy resident files that relate to any matter that is involved in litigation if the facility knows the litigation has not been finally resolved.

Source Note: The provisions of this §506.34 adopted to be effective July 25, 2004, 29 TexReg 6911; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2467