Client Records and Retention
Sets what every client record must contain, including the signed acknowledgments the rule requires, how records are kept confidential and secure, how they are released, and the five-year retention period after discharge.
About this policy
- Policy number
- TX-RM-01
- Version
- 1.0
- Main rule
- 26 TAC §558.301
- Library
- Texas home care · 46 policies
- Category
- Records
- Sections
- 14
In short
- Fill in the visit record before you leave the home. Write what you did, and anything you could not do and why.
- Never erase or cover a mistake. Draw one line through it, then write the correction, the date, and your initials.
- Bring paper visit records to the office within seven days of the visit.
- Keep client information private. Only talk about a client with people who need to know.
- If anyone asks to see or copy a client’s records, send them to the office. Never hand records out yourself.
What's inside
14 sections. The full text comes with the One-time Policy Pack.
- Terms of Reference
- 1. Purpose
- 2. Scope
- 3. Definitions
- 4. Policy Statement (26 TAC §558.301)
- 5. Content of the Client Record
- 6. Procedure
- 7. Responsibilities
- 7.1 Staff Training
- 8. Records and Compliance Monitoring
- 9. References
- 10. Related Documents
- 11. Approval
- 12. Revision History
An inspector may ask
- Pull three client records and show me the signed acknowledgments the rule requires.
- How long do you keep a client record after discharge, and where?
See Cura Core with your agency's name on it.
Choose your state and type of agency, buy your Policy Pack online and get your sign-in by email. Already a customer? Sign in to your portal.