5400, Client Health Records and Documentation of Encounters

Revision 23-4; Effective Nov. 17, 2023

Requirement for Documentation of Reproductive Health Services

All clients should receive services related to reproductive health or contraception at least annually. Clients using long-acting reversible contraception (intrauterine device or implantable hormonal contraceptive agent) and patients who have undergone permanent sterilization may continue to receive services under the program if they meet eligibility requirements. 

The guiding principle of FPP is to improve the reproductive health of clients to ensure every pregnancy and every baby is healthy. At each client encounter, including encounters for treatment of other conditions (for example, an abnormal Pap smear follow-up), the provider must educate the client on how the service being provided relates to reproductive health or contraception, and this must be documented in the client record.

For clients who have undergone sterilization and for women who are post-menopausal or have had a hysterectomy, this counseling and documentation are not required when receiving covered services. This must be documented in the medical record at least annually.

Individual Health Records and Documentation of Encounters

Providers must ensure that a client health record (medical record) is created for every person who obtains clinical services. See Section 3700, Client Records Management.

All client health records must be:

  • a complete, legible and correct documentation of all clinical encounters, including those that take place by phone;
  • written in ink, without erasures or deletions, or documented in the Electronic Health Record (EHR) or Electronic Medical Record (EMR);
  • signed by the provider making the entry, including name of provider, provider title and date for each entry (Note: Electronic signatures are allowable to document provider review of care, but stamped signatures are not allowable);
  • readily accessible to ensure continuity of care and availability to clients; and
  • systematically organized to allow easy documentation and prompt retrieval of information.

The client health record must include: 

  • the client’s identification and personal data, including financial eligibility;
  • the client’s preferred language and method of communication;
  • the client’s contact information, including the best way and alternate ways to reach the person to ensure continuity of care, confidentiality and compliance with Health Insurance Portability and Accountability Act (HIPAA) regulations;
  • the client’s problem list, updated as needed at each encounter, indicating significant illnesses and medical conditions;
  • a complete medication list, including prescription and nonprescription medications as well as dietary supplements, updated at each encounter;
  • a complete listing of all medication allergies and adverse reactions, and other allergic reactions, displayed in a prominent place and confirmed or updated at each encounter; 
    • if the person has no known allergies, this should be properly noted;
  • documentation of the person’s past medical history to include all serious illnesses, hospitalizations, surgical procedures, pertinent biopsies, accidents, exposures to blood products and mental health history;
  • a record or history of immunizations, including immunity to rubella based on a history of vaccine or documented serology testing;
  • the client’s health risk survey and assessment, including past and current tobacco, alcohol and substance use or misuse, domestic or intimate partner violence or abuse (for any positive result, the person must be offered referral to a family violence shelter in compliance with Texas Family Code, Chapter 91), occupational and environmental hazard exposure, environmental safety (for example, seat belt use, car seat use and bicycle helmets), nutritional and physical activity assessment, and living arrangements, updated as appropriate at each encounter;
  • an encounter-relevant history and physical examination pertinent to the person’s reason for presentation, with appropriate laboratory and other studies as indicated, updated at each encounter;
  • a plan of care, updated as appropriate, consistent with diagnoses and assessments, which in turn are consistent with clinical findings;
  • documentation of recommended follow-up care, scheduled return visit dates and follow-up for missed appointments;
  • documentation of informed consent or refusal of services, to include at a minimum:
    • a general consent for treatment;
    • a person’s refusal of testing;
    • sterilization consent forms (noted in Section 5620), if applicable;
    • a completed Texas Medical Disclosure Panel Consent form for surgical services provided, if applicable; and
    • for required or recommended services refused or declined by the person, documentation of the service offered, counseling provided and the person’s decision to decline; 
  • any special documentation or considerations required for minors (under 18 years old) per the Responsibilities for Treatment of Minors within the Family Planning Program and Healthy Texas Women Program; and
  • an update for every clinic visit, with the reason for the visit and documentation of assessments and the services provided.