See related post “Medical record FAQs”
State guidelines for medical record documentation can be difficult to navigate. Here are the answers to common questions about the management, retention, and release of medical records.
What is considered a medical record?
A medical record includes any records pertaining to the history, diagnosis, treatment, or prognosis of a patient. The Texas Medical Board (TMB) rules in Chapter 165 outline elements that should be included in the medical record, and also states that salient records received from another physician or health care professional involved in the care or treatment of the patient shall be maintained as part of the medical record.
Be careful with default text
Of special note is the potential misuse of electronic medical records (EMRs) or of any other type of charting system that facilitates the use of default text in a patient’s chart. Default text is any pre-inserted text that remains in the chart unless changed by the user.
Some EMRs use language describing “normal findings” in the review of systems. If this default language is not changed, it will remain in the chart indicating that the physician completed a review of systems. If this review of systems was not done or if the findings were not normal and the EMR defaults to “normal,” the record is inaccurate.
When investigating a medical liability claim or a board complaint, if it becomes apparent that these default statements are not true, the patient’s exam may be considered incomplete or the documentation characterized as sloppy.
Notes should be individualized for each patient encounter and relevant sections reviewed to avoid importing incorrect, redundant, and irrelevant information. (1)
How long do I keep medical records in Texas?
For adults — all records must be kept for at least seven years from the date of the last treatment. Keep in mind, “treatment” might include a phone call, a prescription refill, or other contact with the patient. Hospitals are required to keep records for 10 years, and some physicians may also choose to keep office records for 10 years.
For minors — records for minor patients must be kept for at least seven years from the date of last treatment or until the child turns 21, whichever is longer.
Medical records that relate to any civil, criminal, or administrative proceeding may be destroyed only if the physician knows the proceeding has been finally resolved.
For more information, please see Chapter 165 of the Texas Medical Board rules.
Who “owns” the medical record?
The physical documents are the tangible, personal property of the person or entity that created them. However, by law patients have the right to obtain copies of their medical records. The only clear exception in Texas law is in the Medical Practice Act, which states: “If the physician determines that access to the information would be harmful to the physical, mental or emotional health of the patient.” This guideline is outlined in the TMB rules Chapter 165.2.
The physician might be asked to explain why the records or information may be harmful to the patient. See the next question below for details on what is required when denying records to a patient. Never release the original record, except under subpoena and then retain a copy.
Is there a deadline for providing requested medical records?
Texas law gives a deadline of 15 business days to provide medical records upon receipt of a request and any agreed upon fees.
This same deadline also applies if the physician feels it would be harmful to release copies of medical records to a patient. The physician or health care entity has a deadline of 15 business days to provide a written, signed, and dated statement that details the reason for the denial and provides instructions to the requestor on how to file a complaint with the Department of Health and Human Services (HHS) and the TMB. A copy of the denial statement should be placed in the patient’s medical and/or billing records. (1)
Source
1. Texas Medical Board. Texas Medical Board Rule 165.1. Medical records. Available at https://www.tmb.state.tx.us/page/board-rules .
