How to File Medical Records in Texas Nursing Homes

The Texas Department of Human Services highly regulates office administration and holds record keeping and filing under particular scrutiny through the Texas Administrative Code (TAC). Title 40, Part 1, Chapter 19 of the TAC addresses nursing facility administration. Noncompliant facilities face risk of fines, closure and even prosecution. A facility's administrator must designate, in writing, a clinical records supervisor who carries the authority, responsibility and accountability for all functions of the records office.

Things You'll Need

• End-tab file folders
• Color-coded labels

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Instructions

• 1

  Review your facility's policies and procedures on record confidentiality. This will serve as your guide when filing new and archived records. If your facility does not have a written policy on record confidentiality, you must create and implement one immediately, as directed by TAC 19.1912.

• 2

  Establish a file in-box and out-box (protected by records staff) with a sign-out system. This system must offer complete security and prevent unauthorized access to records, as required by TAC 19.1910. (Two labeled trays at an unattended counter do not qualify as a secure in-box/out-box system.) Access to records must require a physician's order. Record all physician orders, as well as all file activity.

• 3

  Use color-coded labels to make files easy to find. Assign certain colors to letters of the alphabet and file by the resident's last name. For example, all A to C files receive green labels, D to F have orange labels, and so on. If your facility uses a clinical record numbering system, apply the color-coded method to it and file accordingly. (Green labels for records 1200 to 1499, orange for 1500 to 1799, etc.)

• 4

  Designate storage for active and inactive files. Some offices choose to use open shelving for active files (files of current residents) and cabinet storage for inactive files or archives. TAC 19.1910 requires nursing facilities to retain medical records for five years from the date that medical services end. If your facility cares for minors, their records must be kept for three years after the resident reaches legal age under Texas law.

• 5

  Create a face sheet for each file. This sheet typically gives basic information on the resident (name, date of birth, room number, clinical record number, etc.) as well as a checklist of documentation that the file should contain. Face sheets vary by facility and are generally left to administrative discretion. However, TAC 19.1911 requires that all face sheets give the name, mailing address and telephone numbers of the attending physician.

• 6

  Assemble files while ensuring that each is complete with sufficient information to identify and care for the resident. The TAC requires that a file contain, at the minimum, the resident's full name, home/mailing address, Social Security number, health insurance claim numbers, date of birth, and clinical record number (if applicable). Review TAC 19.1911 for all requirements regarding file contents.

• 7

  Shred or incinerate files that you no longer are required to keep. When you destroy a file, you must document the resident name, clinical record number (if used), and Social Security number, Medicare/Medicaid number, or the date of birth of the resident. The person who disposes of the file must date and sign this document.