Oregon Oregon Health Authority, Public Health Division

Rule Rule 333-027-0150
Clinical Records


General Requirements for Clinical Records:

(1)

An agency shall maintain, for each patient, a clinical record that covers the service(s) the agency provides directly, or through contract with another agency. All entries in the patient’s clinical record must be dated and authenticated. Authentication of an entry requires the use of a unique identifier such as a signature, code thumbprint, voice print, or other means, that provides identification and the title of the individual responsible for the entry. Clinical notes shall be written the day services are rendered and shall be incorporated into the clinical record at least weekly. The agency shall maintain an approved list of standard abbreviations, signs and symbols for use in the clinical record.

(a)

The record of each patient receiving home health services shall contain pertinent past and current findings. The findings shall include, but not be limited to, history and physical examination, and hospital discharge summary. The record shall contain other appropriate information such as: patient identifying information; name of physician; signed and dated clinical and progress notes; copies of summary reports that have been sent to the physician; and a discharge summary.

(b)

The record shall contain the patient’s plan of treatment.

(c)

Clinical records shall contain all original or facsimile physician orders and agency caregiver documentation.

(2)

Retention and Protection of Records:

(a)

The administrator of the agency shall be responsible for proper preparation, adequate content, and preservation of the clinical records. The agency shall permit authorized personnel of the Division to review clinical records as necessary to determine compliance with these rules.

(b)

An agency shall have written policies governing access to, and maintenance, retention, utilization, storage, and disposition of all clinical records.

(c)

An agency shall complete all clinical records of discharged patients within 30 calendar days of the patient’s discharge.

(d)

Clinical records are the property of the agency.

(e)

Upon a patient’s request, the agency shall provide information from the patient’s clinical record related to the patient’s condition and the care provided.

(f)

An agency shall ensure that original clinical records are readily retrievable. Clinical records may be retained on paper, microfilm, electronic, or other media.

(g)

An agency shall keep all clinical records for a period of 10 years after the date of the patient’s last discharge from the agency.

(h)

An agency shall keep clinical records in a safe and secure environment that will protect them from damage and harm.

(i)

If an agency changes ownership, the agency shall retain all clinical records in original or microfilmed form and it shall be the responsibility of the successor agency to protect and maintain these records.

(j)

In the event of dissolution of an agency, the agency administrator shall notify the Division where the clinical records will be stored.

(k)

The agency shall retain non-medical records according to the policy of the individual agency.

(l)

An agency shall comply with ORS 192.518 through 192.529, which governs the use and disclosure of patient’s protected health information.
Source

Last accessed
Jun. 8, 2021