TMB: More Must-Haves for Medical Records

The Texas Medical Board updated its medical records rule to reflect today's use of electronic health records and forms of communication. These changes to rule §165.1 took effect May 20, 2015.

1.The amended rule clarifies that it applies to all types of records. 

§165.1(a) Contents of Medical Record. Regardless of the medium utilized, each licensed physician of the board shall maintain an adequate medical record for each patient that is complete, contemporaneous and legible.

2. A new subsection adds relevant email, texts, or other electronic communication to the elements of an "adequate medical record." This would also apply to nonelectronic communication, such as a conversation between a physician and patient at the grocery store, but the onus for the change was electronic communications.

§165.1(a)(8) Include a summary or documentation memorializing communications transmitted or received by the physician about which a medical decision is made regarding the patient.  

3. Another new subsection says that all populated fields in an electronic medical record must be accurate for that patient. Beware of relying on boilerplate text, prepopulated fields, or copying and pasting notes or other information from one visit to the next, or one patient to another.

This is the most confusing part of the rule for physicians. Thus TMB required, as a condition of adoption, that TMB staff publish an FAQ, which, among other things, will define/explain more explicitly what "non-biographical populated fields" are and are not.

§165.1(a)(10) All non-biographical populated fields, contained in a patient's electronic medical record, must contain accurate data and information pertaining to the patient based on actual findings, assessments, evaluations, diagnostics or assessments as documented by the physician.

Look for a story about this rule change in the upcoming July 2015 Texas Medicine. Read about the background of the amendments in TMA Action.

Published June 23, 2015

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Last Updated On

June 29, 2015

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