Revision 25-3; Effective Oct. 29, 2025

Requirement for Documenting Reproductive Health Services

All clients should receive services related to reproductive health or contraception at least annually. Clients who use long-acting reversible contraception, such as an intrauterine device or implantable hormonal contraceptive device, 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 make sure every pregnancy and every baby is healthy. At each client encounter, including those for treatment of other conditions such as an abnormal Pap smear follow-up, the provider must educate the client on how the service being provided relates to reproductive health or contraception. 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.

Client Health Records and Documentation of Encounters

Providers must make sure a client health record, the medical record, is created for every person who obtains clinical services. Refer to 3600, 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 who makes the entry, including name of provider, provider title and date for each entry. Note: Electronic signatures are allowed to document provider review of care, but stamped signatures are not allowed.
• readily accessible to ensure continuity of care and availability to clients.
• systematically organized to allow easy documentation and prompt retrieval of information.

The client health record must include the person’s:

• identification and personal data, including financial eligibility.
• preferred language and method of communication.
• contact information, including the best and alternate ways to reach the person to ensure continuity of care, confidentiality and compliance with Health Insurance Portability and Accountability Act (HIPAA) regulations.
• problem list, updated as needed at each encounter, which indicates significant illnesses and medical conditions.
• complete medication list, including prescription and nonprescription medications and dietary supplements, updated at each encounter.
• complete list 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 past medical history, which includes all:
  • serious illnesses;
  • hospitalizations;
  • surgical procedures;
  • pertinent biopsies;
  • accidents;
  • exposures to blood products; and
  • mental health history.
• record or history of immunizations, including immunity to rubella based on a history of vaccine or documented serology testing.
• 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 per Texas Family Code, Chapter 91;
  • occupational and environmental hazard exposure;
  • environmental safety such as seat belt use, car seat use and bicycle helmets;
  • nutritional and physical activity assessment; and
  • living arrangements, updated as appropriate at each encounter.
• encounter-relevant history and physical exam pertinent to the person’s reason for presentation, with appropriate laboratory and other studies as indicated, updated at each encounter.
• plan of care, updated as appropriate, that is consistent with diagnoses and assessments 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 that includes, at a minimum:
  • a general consent for treatment;
  • a person’s refusal of testing;
  • sterilization consent forms, noted in 5620, Sterilization Procedures, Consent, Billing and Reporting, 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 documents or considerations required for minors younger than 18 years per the Responsibilities for Treatment of Minors within the Family Planning Program and Healthy Texas Women Program (PDF).
• an update for every clinic visit, with the reason for the visit and documentation of assessments and the services provided.