Texas Register, Volume 30, Number 43, Pages 6973-7094, October 28, 2005 Page: 7,044
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policy shall include a procedure for addressing complaints related to
billed services and supplies.
(k) The governing body shall adopt, implement and enforce
written policies to ensure compliance with applicable state laws.
(1) Informed consent for abortion. An ASC that performs abor-
tions shall adopt, implement and enforce a policy to ensure compliance
with Health and Safety Code, Chapters 171 and 245, Subchapters A and
B (relating to Abortion and Informed Consent).
135.9. Medical Records.
(a) The ASC shall develop and maintain a system for the col-
lection, processing, maintenance, storage, retrieval, and distribution of
patient medical records.
(b) An individual medical record shall be established for each
person receiving care.
(c) All clinical information relevant to a patient shall be readily
available to health care practitioners involved in the care of that patient.
(d) Except when otherwise required by law, any record that
contains clinical, social, financial, or other data on a patient shall be
strictly confidential and shall be protected from loss, tampering, alter-
ation, destruction, and unauthorized or inadvertent disclosure.
(e) A person shall be designated to be in charge of medical
records whose responsibilities include, but are not limited to:records;
request;
record;(1) the confidentiality, security, and safe storage of medical
(2) the timely retrieval of individual medical records upon
(3) the specific identification of each patient's medical(4) the supervision of the collection, processing, mainte-
nance, storage, retrieval, and distribution of medical records; and
(5) the maintenance of a predetermined organized medical
record format.
(f) Policies concerning medical records shall follow current
statute in regard to retention of active records, retirement of inactive
records and the release of information contained in the record.
(g) Except when otherwise required by law, the content and
format of medical records, including the sequence of information, shall
be uniform.
(h) Reports, histories and physicals, progress notes, and other
patient information (such as laboratory reports, x-ray readings, and
consultation) shall be incorporated into the medical record in a timely
manner.
(i) Medical records shall be available to authorized health care
practitioners any time the ASC is open to patients.
(j) The ASC record shall include the following:
(1) patient identification;
(2) allergies and untoward reactions to drugs recorded in a
prominent and uniform location;
(3) all pre-operative, post-operative medications admin-
istered and drug/dose/route/frequency/quantity of all post-operative
drugs dispensed to the patient by the ASC and entered on the patient's
record;
(4) significant medical history and results of physical ex-
amination;(5) preop diagnostic studies entered before surgery, if re-
quired by policy or ordered by a physician or advanced practice nurse;
(6) findings and techniques of the operation (operative re-
port);
(7) pathology report on all tissues removed during surgery
except those exempted by the governing body;
(8) anesthesia administration record that includes either
general, local, or regional anesthetic;
(9) documentation of a properly executed informed con-
sent;
(10) evidence of evaluation of the patient by a physician or
advanced practice nurse prior to dismissal;
(11) evidence that the patient left the facility in the com-
pany of a responsible adult unless a physician or advanced practice
nurse writes an order that the patient may leave the facility without the
company of a responsible adult; and
(12) for patients with a length of stay greater than eight
hours, an evaluation of nutritional needs and evidence of how identified
needs were met.
(k) Appropriate medical advice given to a patient by telephone
shall be entered in the patient's medical record and appropriately signed
or initialed.
(1) Entries in patients' medical records shall be legible to clin-
ical personnel and shall be accurate and completed promptly.
(m) Any notation in a patient's medical record indicating di-
agnostic or therapeutic intervention as part of clinical research shall be
clearly contrasted with entries regarding the provision of nonresearch
related care.
(n) When necessary for assuring continuity of care, summaries
of records of a patient who was treated elsewhere (such as by another
physician, hospital, ambulatory surgical center, nursing home, or con-
sultant) shall be obtained.
(o) When necessary for assuring continuity of care, summaries
or photocopies of the patient's record shall be transferred to the health
care practitioner to whom the patient was referred and, if appropriate,
to the facility where future care will be rendered.
(p) Certain repetitive procedures are suitable for pre-printed
operative notes. These operative notes are suitable as long as they are
approved by the governing body and signed by the surgeon and transmit
to a knowledgeable reader the events of the surgical procedure.
(q) All final tissue and abnormal cytology reports from the
Medicare approved reference laboratory shall be signed by a pathol-
ogist.
135.11. Anesthesia and Surgical Services.
(a) Anesthesia services.
(1) Anesthesia services provided in the ASC shall be lim-
ited to those that are approved by the governing body, which may in-
clude the following.
(A) Topical anesthesia--an anesthetic agent applied di-
rectly or by spray to the skin or mucous membranes, intended to pro-
duce transient and reversible loss of sensation to the circumscribed
area.
(B) Local anesthesia--administration of an agent that
produces a transient and reversible loss of sensation to a circumscribed
portion of the body.30 TexReg 7044 October 28, 2005 Texas Register
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Texas. Secretary of State. Texas Register, Volume 30, Number 43, Pages 6973-7094, October 28, 2005, periodical, October 28, 2005; Austin, Texas. (https://texashistory.unt.edu/ark:/67531/metapth97316/m1/70/?q=%22%22~1&rotate=270: accessed July 16, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu; crediting UNT Libraries Government Documents Department.