(a) In accordance with accepted principles of practice, a center must establish and maintain a medical record system to ensure that the services provided to a minor are completely and accurately documented, readily accessible, and systematically organized to facilitate the compilation and retrieval of information.
(b) A center must establish a record for a minor and must maintain the record in accordance with and contain the information described in subsection (g) of this section.
(c) A center must keep a single file for services provided to a minor and a minor's parent.
(d) A center must adopt and enforce written procedures regarding the use and removal of records, the release of information, and when applicable, the incorporation of clinical, progress, or other notes into the medical record.
(e) A center may not release any portion of a minor's medical record to anyone other than an adult minor and a minor's parent, except as allowed by law.
(f) A center must establish a secure area for original active medical record storage at the center's place of business.
  (1) A center must ensure that a minor's medical record is treated as confidential, safeguarded against loss and unofficial use, and maintained according to professional standards of practice.
  (2) A center must keep a minor's medical record in original form, as a microfilmed copy, on an electronic system, or as a certified copy.
  (3) A medical record in its original form is a signed paper record or an electronically signed computer record.
  (4) A center must ensure that computerized medical records meet the requirements of paper records, including protection from unofficial use as specified in subsection (g) of this section and retention for the period specified in §15.1004 of this division (relating to Retention of Records).
  (5) A center must ensure that an entry to a medical record regarding the delivery of services is not altered without evidence and explanation of the alteration.
  (6) A center must ensure that an entry to a minor's medical record is current, accurate, legible, clear, complete, and appropriately authenticated and dated with the date of entry by the individual making the entry. The record must document all services provided on behalf of the center. The center must not use correction fluid or tape in the record. The center must make corrections by striking through the error with a single line and including the date the correction was made and the initials of the person making the correction.
  (7) A center must store the record of an inactive minor's medical record on paper, microfilm, or electronically. The center must secure the medical record and ensure that it is readily retrievable by the center staff.
(g) Each medical record must include the following information as applicable to the services provided on behalf of a center:
  (1) a minor's referral and application for services including, but not limited to:
    (A) a minor's full name;
    (B) sex and date of birth;
    (C) the name, address and telephone number of a minor's parent, or others as identified by a minor's parent;
    (D) a minor's prescribing physician's name and telephone numbers, and an emergency contact number; and
    (E) a minor's prescribing physician's initial order for services;
  (2) comprehensive assessments, pertinent medical history including allergies and special precautions and subsequent assessments;
  (3) plans of care, nursing care plans and other plans as applicable;
  (4) verbal orders of a physician reduced to writing and signed by the physician in accordance with the center's policy as required by §15.702 of this subchapter (relating to Receiving Physician Orders);
  (5) documentation of nutritional counseling and special diets, as appropriate;
  (6) clinical and progress notes from all professionals providing services to a minor;
  (7) documentation of all known services and significant events;
  (8) current medication list;
  (9) medication administration record, if medication is administered by center staff;
  (10) current immunization record;
  (11) written acknowledgment of an adult minor's and a minor's parent's receipt of written notification of the requirements of §15.901 of this subchapter (relating to Rights and Responsibilities);
  (12) written acknowledgment of an adult minor's and a minor's parent's receipt of a center's policy relating to the reporting of abuse, neglect, or exploitation of a minor;
  (13) written acknowledgement of an adult minor's and a minor's parent's receipt of the notice of advance directives;
  (14) written acknowledgement of an adult minor's and a minor's parent's receipt of the center's policies relating to discipline and guidance;
  (15) documentation demonstrating that an adult minor and a minor's parent have been informed of how to register a complaint in accordance with §15.901 of this subchapter;
  (16) discharge summary, including the reason for discharge or transfer and a center's documented notice to an adult minor, a minor's parent, a minor's prescribing physician, and other individuals as required in §15.608 of this subchapter (relating to Discharge or Transfer Notification);
  (17) services provided to a minor's parent; and
  (18) all consent and election forms, as applicable.
(h) The center must ensure that clinical and progress notes are written the day service is rendered and incorporated into the medical record no later than two business days after the services are rendered.

Source Note: The provisions of this §550.1001 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875