26 TAC §558.301 - Client Records

What this rule requires your agency to do

• 1Each entry must be current, accurate, signed, and dated with the date of entry by the individual making it; correction fluid/tape must not be used, and corrections must be made by striking through the error with a single line, dated, and initialed (§558.301(a)(7)).(26 TAC §558.301 - Client Records)
• 2Original active client records must be stored at the place of business from which services are provided and must not be stored at an administrative support site or records storage facility (§558.301(a)(4)).(26 TAC §558.301 - Client Records)
• 3Clinical and progress notes must be written the day service is rendered and incorporated into the client record within 14 working days (§558.301(a)(9)(D)).(26 TAC §558.301 - Client Records)
• 4An agency must retain original client records for a minimum of five years after discharge of the client and may not destroy records relating to unresolved litigation (§558.301(b)(1)-(2)).(26 TAC §558.301 - Client Records)
• 5Each client record must include the care plan, plan of care, or individualized service plan as applicable; an ISP for a personal assistance service client must comply with §558.404 (§558.301(a)(9)(C)).(26 TAC §558.301 - Client Records)
• 6Records must document that effective interchange, reporting, and coordination of care occurs as required in §558.288 (§558.301(a)(9)(I)).(26 TAC §558.301 - Client Records)
• 7An agency must establish and maintain a client record system ensuring care and services provided to each client are completely and accurately documented, readily accessible, and systematically organized (§558.301(a)).(26 TAC §558.301 - Client Records)