(a) The medical record must be a complete, contemporaneous, and legible documented account of each patient encounter by a physician or delegate.(b) To the extent applicable, a medical record must include, at a minimum:(1) a reason for the encounter, relevant history, physical examination findings (ensuring any pre-populated fields contain current and accurate patient information), and any diagnostic test results;(2) an assessment, clinical impression, and diagnosis;(3) a plan for care (including diagnostics, risk factors, consults, referrals, ancillary services, discharge plan if appropriate, patient/family education, disclosures, and follow-up instructions), treatments, and medications (including amount, frequency, number of refills, and dosage);(4) late entries, if any, that indicate the time and date entered, as well as the identity of the person who made the late entry;(5) summary or documentation of communications with the patient;(6) sufficient documentation of requests for records from other providers and any records received;(7) clear identification of any amendment or correction to the medical record, including the date it was amended or corrected and the identity of the author of the amendment or correction, with the original text remaining legible; and(8) documentation of a review of the patient's Texas Prescription Monitoring Program (PMP) prescribing history.