(a) A resident's clinical record must meet all documentation requirements in the HHSC rule at Texas Administrative Code, Title 1, Part 15, Chapter 371, Subchapter C (relating to Utilization Review).
(b) The clinical record of each resident must contain:
  (1) a face sheet that contains the attending physician's current mailing address and telephone numbers;
  (2) sufficient information to identify and care for the resident, to include at a minimum:
    (A) full name of resident;
    (B) full home or mailing address, or both;
    (C) social security number;
    (D) health insurance claim numbers, if applicable;
    (E) date of birth; and
    (F) clinical record number, if applicable;
  (3) a record of the resident's assessments, including 15 months of MDS records;
  (4) the comprehensive care plan and services provided;
  (5) a permanency plan, for residents younger than 22 years of age;
  (6) the results of any Preadmission Screening and Resident Review;
  (7) signed and dated clinical documentation from all health care practitioners involved in the resident's care, with each page identifying the name of the resident for whom the clinical care is intended;
  (8) any directives or medical powers of attorney as described in §19.419 of this chapter (relating to Advance Directives);
  (9) discharge information and a discharge summary in accordance with §19.803 of this chapter (relating to Discharge Summary (Discharge Plan of Care));
  (10) at admission or within 14 days after admission, documentation of an initial medical evaluation, including history, physical examination, diagnoses and an estimate of discharge potential and rehabilitation potential, and documentation of a previous annual medical examination;
  (11) authentication of a hospital diagnosis, which may be in the form of a signed hospital discharge summary, a signed report from the resident's hospital or attending physician, or a transfer form signed by the physician;
  (12) the physician's signed and dated orders, including medication, treatment, diet, restorative and special medical procedures, and routine care to maintain or improve the resident's functional abilities (required for the safety and well-being of the resident), which must not be changed either on a handwritten or computerized physician's order sheet after the orders have been signed by the physician unless space allows for additional orders below the physician's signature, including space for the physician to sign and date again;
  (13) arrangements for the emergency care of the resident in accordance with §19.1204 of this chapter (relating to Availability of Physician for Emergency Care);
  (14) observations made by nursing personnel according to the time frames specified in §19.1010 of this chapter (relating to Nursing Practices);
  (15) items as specified on the MDS assessment;
  (16) current information, including:
    (A) PRN medications and results;
    (B) treatments and any notable results;
    (C) physical complaints, changes in clinical signs and behavior, mental and behavioral status, and all incidents or accidents;
    (D) flow sheets, which may include bathing, restraint observation or release documentation, elimination, fluid intake, vital signs, ambulation status, positioning, continence status and care, and weight;
    (E) a record of dietary intake, including deviations from normal diet, rejection of substitutions, and physician's ordered snacks or supplemental feedings;
    (F) a record of the date and hour a drug or treatment is administered; and
    (G) documentation of a special procedure performed for the safety and well-being of the resident; and
  (17) laboratory, radiology and other diagnostic services reports, as required by §19.1908 of this subchapter (relating to Laboratory Services) and §19.1909 of this subchapter (relating to Radiology and Other Diagnostic Services).

Source Note: The provisions of this §554.1911 adopted to be effective August 1, 2000, 25 TexReg 6779; amended to be effective May 1, 2002, 27 TexReg 2834; amended to be effective September 1, 2008, 33 TexReg 7264; amended to be effective August 31, 2015, 40 TexReg 5461; amended to be effective July 21, 2016, 41 TexReg 5203; 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