OAR 166-475-0065
Health Services Records
(1)
Client Records Records document provision of health-related services to clients on an outpatient basis by offices other than the student health center. Examples of types of services are speech therapy; hearing testing, and cholesterol screening. This series may include but is not limited to tests; goals and objectives; diagnostic reports; questionnaires; and related data. (Retention: 7 years after last service or until client reaches age 21, whichever is longer, destroy)(2)
Communicable Disease Records This series fulfills the public health requirement of reporting the discovery of communicable disease. This series may include but is not limited to laboratory test results; name and address of client or patient; date; and person making referral. Information is transferred to the county health department, but the log is maintained by the laboratory. (Retention: 5 years, destroy)(3)
Counseling, Psychological, and Psychiatric Case Records Records document all clients who are provided counseling, psychological, and psychiatric services by the institution’s counseling center. Clinicians provide treatment concerning personal problems, academic concerns, and career concerns. The psychiatric consultant provides psychiatric care to some student clients. Records may include extensive notes made by providers concerning the assessment, diagnosis, treatment and contacts (written, telephone, or in person) with each client; referral letters; release of information agreements; letters to agencies or others concerning the clients; and related documentation. (Retention: 7 years after last contact, destroy)(4)
Health History Forms Records document a student’s medical history. The series contains student medical history forms for students who have never visited an institutional student health center and therefore do not have a medical record on file. These forms are a prerequisite for enrollment at most institutions. (Retention: 7 years after last service, destroy)(5)
Immunization Reporting Records Records document compliance with Oregon State Health Division reporting requirements for immunizations given to patients. Records may include immunization log sheets; annual reports; ITARS (Immunization Tracking and Recall System) documentation and related correspondence. (Retention: (a) 25 years from last date of service for ITARS records, destroy (b) 10 years for immunization log sheets and annual reports, destroy (c) 7 years after last service for all other records, destroy)(6)
Laboratory Inspection Records Records document in-house inspection of laboratory equipment on a quarterly basis. This series may include but is not limited to a checklist of all equipment; calibrations; and conditions. (Retention: (a) For the life of the equipment for calibrations, destroy (b) 3 years for all other records, destroy)(7)
Laboratory Test Requests Records document physician orders for laboratory tests for students receiving services at the student health center. This series may include but is not limited to name of student; date; test(s) ordered; and physician’s signature. (Retention: 2 years, destroy)(8)
Licensure Records Records document the professional and regulatory issuance of credentials to individuals and facilities providing services within the student health center. This series may include but is not limited to license applications; College of American Pathologists comparative test results for laboratory licensing; Oregon Pharmacy Board Retail Drug Outlet/Controlled Substance Registration (license) and inspection reports; individual employee professional licenses; and related correspondence. (Retention: Until superseded or obsolete, destroy)(9)
Medical Records Records document the medical services history provided for students treated by the student health center. This series may include but is not limited to appointment request slips; summary sheets; bacteriology test results; treatment record forms; diagnosis sheets; health history/screening sheets; initial evaluation/assessment sheets; referral sheets; health center billing statements; personal health history sheets; dental examination sheets and X-rays; laboratory test results; physical therapy notes; X-ray release forms; X-ray requisitions with narrative of radiologist; notes; memoranda; and related correspondence. (Retention: 7 years after last service or until client reaches age 21, whichever is longer, destroy)(10)
Non-Student Medical Records Records document medical services provided to non-students by the institution’s student health center, such as allergy shot, vaccines, and blood pressure checks. Records include medical history forms; notations of services provided and dates; payment information; and related correspondence. (Retention: 7 years after last service or until client reaches age 21, whichever is longer, destroy)(11)
Patient Logs Records document patients who visit the student health center (both in-patients and out-patients). It may also be used to create annual census reports and 3-year census comparisons. Log information may include the date and time that the patient came in; the physician assigned; diagnosis; admission/discharge date; length of stay; and remarks. (Retention: 3 years, destroy)(12)
Patient Satisfaction Surveys Records document patient comments on services provided by the student health center and is used to plan for a change in services. The surveys may include but are not limited to rating of services; type of services rendered; statistics about the student; and possibly names and addresses. (Retention: 3 years, destroy)(13)
Pharmacy Prescription Dispensation Records Records document individual, daily summary, and annual summary record of initial drug dispensation and refills administered by the department as required by the Oregon State Pharmacy Board. This series may include but is not limited to prescription slips; in-house computer-generated Rx registers; controlled substance reports; and data base purge reports. (Retention: 3 years, destroy)(14)
Practitioner Schedules Records document the practitioners’ work schedules which are used to clarify assigned responsibilities. This series includes dates and times of assignments; practitioner names; and responsibilities. (Retention: 2 years, destroy)(15)
Radiographic Quality Assurance Records Records document the setting of measurable standards and procedures for radiographic safety and professional quality by professionals on staff. This series may include but is not limited to reports by the radiographic staff; quality assurance committee notes; and staff reviews. (Retention: 3 years, destroy)(16)
Student Health Insurance Records Records document students’ insurance coverage activity under institution insurance policies. This series may include but is not limited to benefit explanations; payment summaries; photocopies of checks; invoices; policy change sheets; ledgers; individual student correspondence relating to their coverage; and related correspondence with the insurance company. (Retention: 2 years after expiration of policy, destroy)(17)
Surgical Instrument Sterilization Records Records document the sterilization of surgical instruments used by the student health center. This series may include but is not limited to autoclave recording charts and log sheets indicating date; load number; items sterilized; and temperature/time settings. (Retention: 1 year, destroy)(18)
X-Rays This series consists of student X-rays taken by student health center staff. X-rays are stored alphabetically in envelopes identified by year, name, and view. This series may also include but is not limited to a log of X-rays going out and coming in for professional reference and related documentation. (Retention: 7 years after date of last service, destroy).
Source:
Rule 166-475-0065 — Health Services Records, https://secure.sos.state.or.us/oard/view.action?ruleNumber=166-475-0065.