1. (a) An adequate chiropractic record, as described in this section, for each patient shall be maintained for a minimum of six years from the date of last treatment.
2. (b) If a patient was younger than 18 years of age when last treated by a licensee, the chiropractic records of the patient shall be maintained until the patient reaches age 21 or for six years from the date of last treatment, whichever is longer.
3. (c) Chiropractic records that relate to any civil, criminal or administrative proceeding shall not be destroyed until the proceeding has been finally resolved.
4. (d) Chiropractic records shall be maintained for such longer length of time than that imposed by this section when mandated by other federal or state statute or regulation.
5. (e) Each licensee practicing at a facility is equally responsible for compliance with this section.
6. (f) Licensees shall maintain patient and billing records in a manner consistent with the protection and welfare of the patient. A licensee's patient records shall support all diagnoses, treatments, and billing. Records shall be timely, dated, accurate, legible, and signed or initialed by the licensee or the person providing treatment. Electronic signatures are acceptable.
7. (g) Licensees are required, as directed in subsections (h) and (i) of this section, to perform an appropriate history and exam based on the nature of the presenting problem described by the patient and in accordance with accepted documentation guidelines. Accepted guidelines include, but are not limited to, the latest edition of the American Chiropractic Association Clinical Documentation Manual, American Medical Association CPT Code Book, 1997 DG and/or Chiropractic Service Manual Guidelines set forth by CMS.

8. (h) Other than consultations, reports of findings, and/or non-therapeutic interaction(s), all patient records for an initial visit shall include:

   1. (1) Patient History;
   2. (2) Description of symptomatology or wellness care;
   3. (3) Examination findings, including imaging and laboratory records when clinically indicated;
   4. (4) Diagnosis;
   5. (5) Prognosis;
   6. (6) Assessment(s);
   7. (7) Treatment Plan;
   8. (8) Treatment provided or recommended; and
   9. (9) Periodic reassessment(s) when appropriate, with a minimum of once per calendar year.

9. (i) Other than a continuation of previously prescribed treatment plans, consultations, reports of findings, and/or non-therapeutic interaction(s), patient records for all subsequent visits shall include:

   1. (1) Updated History:

      1. (A) Review of the chief complaint(s);
      2. (B) Changes, if any, since the last visit;

   2. (2) Physical Exam:

      1. (A) Examination of the area involved in the diagnosis;
      2. (B) Assessment of any change in the patient's condition since last visit;

   3. (3) Treatment:

      1. (A) Documentation of treatment given;
      2. (B) Documentation of patient's response to the treatment rendered on that visit;
      3. (C) Change in treatment plan or planned referrals if indicated.
10. (j) All licensed chiropractors shall observe and comply with all documentation laws pertaining to health care providers under state and federal law. Nothing within this section should be construed to constrain or limit the obligation of chiropractors to meet duly authorized law, rules and regulations.

Source Note:The provisions of this §76.2 adopted to be effective January 29, 2015, 40 TexReg 379; amended to be effective March 29, 2018, 43 TexReg 1859; transferred effective November 1, 2018, as published in the Texas Register October 19, 2018, 43 TexReg 6963.