OAR 333-076-0165
ASC Medical Records

(1) A medical record shall be maintained for every patient admitted for care.
(2) A legible reproducible medical record shall include at least the following (if applicable):
(a) Admitting identification data including date of admission;
(b) Chief complaint;
(c) Pertinent family and personal history;
(d) History and physical. This history and physical shall be completed no more than 30 days prior to the initiation of any procedure. Sufficient time shall be allowed between examination and the initiation of any procedure, to permit review of tests;
(e) Clinical laboratory reports as well as reports on any special examinations. (The original report shall be authenticated and recorded in the patient’s medical record.);
(f) X-ray reports shall be recorded in the medical record and shall bear the identification (authentication) of the originator of the interpretation;
(g) Signed or authenticated report of consultant when such services have been obtained;
(h) All entries in patient’s medical record must be dated, timed, and authenticated:
(A) Verification of an entry requires use of a unique identifier, for example, signature, code, thumbprint, voice print or other means, which allows identification of the individual responsible for the entry;
(B) Verbal orders may be accepted by those individuals authorized by law and by medical staff rules and regulations and shall be countersigned or authenticated within two business days by the ordering health care practitioner or another health care practitioner who is responsible for the care of the patient;
(C) A single signature or authentication of the physician, dentist, podiatrist or other individual authorized within the scope of his or her professional license on the medical record does not suffice to cover the entire content of the record.
(i) Records of assessment and intervention, including but not limited to preprocedure vital sign records, graphic charts, medication records and appropriate personnel notes;
(j) Anesthesia record including records of anesthesia, analgesia and medications given in the course of the operation and postanesthetic condition, signed or authenticated by the person making the entry;
(k) A record of operation dictated or written immediately following surgery and including a complete description of the operation procedures and findings, postoperative diagnostic impression, and a description of the tissues and appliances, if any, removed;
(L) Postanesthesia Recovery (PAR) progress notes including but not limited to vital sign records and other appropriate clinical notes;
(m) Pathology report on tissues and appliances, if any, removed at the operation. The following tissues and appliances may be exempted from pathology exam:
(A) Specimens that, by their nature or condition, do not permit fruitful examination, including but not limited to a cataract, orthopedic appliance, foreign body, or portion of rib removed only to enhance operative exposure;
(B) Therapeutic radioactive sources, the removal of which shall be guided by radiation safety monitoring requirements;
(C) Traumatically injured members that have been amputated and for which examination for either medical or legal reasons is not considered necessary;
(D) Specimens known to rarely, if ever, show pathological change, and the removal of which is highly visible postoperatively, including but not limited to the foreskin from circumcision of a newborn infant;
(E) Placentas that are grossly normal and have been removed in the course of operative and nonoperative obstetrics;
(F) Teeth, provided that the number, including fragments, is recorded in the medical record.
(n) Summary including final diagnosis;
(o) Date of discharge and discharge note;
(p) Autopsy report if applicable;
(q) Informed consent forms that document:
(A) The name of the ASC where the procedure or treatment was undertaken;
(B) The specific procedure or treatment for which consent was given;
(C) The name of the health care practitioner performing the procedure or administering the treatment;
(D) That the procedure or treatment, including the anticipated benefits, material risks, and alternatives was explained to the patient or the patient’s representative or why it would have been materially detrimental to the patient to do so, giving due consideration to the appropriate standards of practice of reasonable health care practitioners in the same or a similar community under the same or similar circumstances;
(E) The manner in which care will be provided in the event that complications occur that require health services beyond what the ASC has the capability to provide. If the ASC has entered into agreements with more than one hospital, the patient must be provided with the most likely possible option, but that the transfer hospital may be dependent on the type of problem encountered.
(F) The signature of the patient or the patient’s legal representative; and
(G) The date and time the informed consent was signed by the patient or the patient’s legal representative;
(r) Documentation of the disclosures required in ORS 441.098 (Health practitioner referral of patient to treatment or diagnostic testing facility); and
(s) Such signed documents as may be required by law.
(3) The completion of the medical record shall be the responsibility of the attending physician:
(a) Medical records shall be completed by the physician, dentist, podiatrist or other individual authorized within the scope of his or her professional license within four weeks following the patient’s discharge;
(b) If a patient is transferred to another health care facility, transfer information shall accompany the patient. Transfer information shall include but not be limited to facility from which transferred; name of physician to assume care; date and time of discharge; current medical findings; current nursing assessment; current history and physical; diagnosis; orders from a physician for immediate care of the patient; operative report, if applicable; TB test, if applicable; other information germane to patient’s condition. If discharge summary is not available at time of transfer, it shall be transmitted as soon as available.
(4) Diagnoses and operations shall be expressed in standard terminology.
(5) The medical records shall be filed in a manner which renders them easily retrievable. Medical records shall be protected against unauthorized access, fire, water and theft.
(6) Medical records are the property of the ASC. The medical record, either in original, electronic or microfilm form, shall not be removed from the institution except where necessary for a judicial or administrative proceeding. Authorized personnel of the Authority shall be permitted to review medical records. When an ASC uses off-site storage for medical records, arrangements must be made for delivery of these records to the health care facility when needed for patient care or other health care facility activities. Precautions must be taken to protect patient confidentiality.
(7) All medical records shall be kept for a period of at least 10 years after the date of last discharge. Original medical records may be retained on paper, microfilm, electronic or other media.
(8) If an ASC changes ownership all medical records in original, electronic or microfilm form shall remain in the ASC or related institution, and it shall be the responsibility of the new owner to protect and maintain these records.
(9) If any ASC shall be finally closed, its medical records may be delivered and turned over to any other health care facility in the vicinity willing to accept and retain the same as provided in section (7) of this rule.
(10) All original clinical records or photographic or electronic facsimile thereof, not otherwise incorporated in the medical record, such as X-rays, electrocardiograms, electroencephalograms, and radiological isotope scans shall be retained for seven years after patient’s last discharge if professional interpretations of such graphics are included in the medical records.
(11) A current written policy on the release of medical record information including patient access to his or her medical record shall be maintained in the facility.
(12) The Authority may require the facility to obtain periodic and at least annual consultation from a qualified medical records consultant, Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT.) The visits of the medical records consultant shall be of sufficient duration and frequency to review medical record systems and assure quality records of the patients. Contract for such services shall be available to the Authority upon request.

Source: Rule 333-076-0165 — ASC Medical Records, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=333-076-0165.

333‑076‑0001
Applicability 333‑076‑0095
Purpose 333‑076‑0101
Definitions 333‑076‑0102
Application for ASC License and Fees 333‑076‑0103
ASC Application Review 333‑076‑0104
Approval of ASC License Application 333‑076‑0107
Denial of ASC License Application 333‑076‑0108
Expiration and Renewal of ASC License 333‑076‑0110
Return of ASC License and ASC Closure 333‑076‑0111
ASC Classification 333‑076‑0114
ASC Complaints 333‑076‑0116
ASC Investigations 333‑076‑0117
ASC Surveys 333‑076‑0118
ASC Health Care Practitioner Credentialing 333‑076‑0119
ASC Governing Body Responsibility 333‑076‑0120
ASC Medical Staff 333‑076‑0125
ASC Personnel 333‑076‑0130
ASC Policies and Procedures 333‑076‑0135
ASC Nursing Services 333‑076‑0137
ASC Surgery Services 333‑076‑0140
ASC Anesthesia Services (If Provided) 333‑076‑0145
ASC Storage, Disposal and Dispensing of Drugs 333‑076‑0150
ASC Emergency Services 333‑076‑0155
ASC Laboratory Services 333‑076‑0160
Care of ASC Patients 333‑076‑0165
ASC Medical Records 333‑076‑0170
ASC Quality Assessment and Performance Improvement 333‑076‑0175
ASC Infection Control 333‑076‑0180
In-service Training for ASC Nurses 333‑076‑0185
ASC Physical Environment 333‑076‑0190
ASC Emergency Preparedness 333‑076‑0246
Waivers 333‑076‑0250
ASC Violations 333‑076‑0255
ASC Informal Enforcement 333‑076‑0260
ASC Formal Enforcement 333‑076‑0265
Civil Penalties, Generally 333‑076‑0270
Approval of ASC Accrediting Organizations 333‑076‑0450
Birthing Centers: Definitions 333‑076‑0470
Birthing Centers: Licensing 333‑076‑0490
Birthing Centers: Submission of Plans 333‑076‑0510
Birthing Centers: Expiration and Renewal of License 333‑076‑0530
Birthing Centers: Denial or Revocation of a License 333‑076‑0550
Birthing Centers: Return of Facility License 333‑076‑0560
Birthing Centers: Classification 333‑076‑0570
Birthing Centers: Hearings 333‑076‑0590
Birthing Centers: Adoption by Reference 333‑076‑0610
Birthing Centers: Division Procedures 333‑076‑0630
Birthing Centers: Administration 333‑076‑0650
Birthing Centers: Service Restrictions 333‑076‑0670
Birthing Centers: Policies and Procedures 333‑076‑0690
Birthing Centers: Health and Medical Records 333‑076‑0710
Birthing Centers: Physical Facility 333‑076‑0800
Extended Stay Center (ESC) Applicability 333‑076‑0805
Application for ESC License and Fees 333‑076‑0810
ESC Application Review 333‑076‑0820
Approval of ESC License Application 333‑076‑0830
Denial of ESC License Application 333‑076‑0840
Expiration and Renewal of ESC License 333‑076‑0850
Return of ESC License and ESC Closure 333‑076‑0860
ESC Surveys 333‑076‑0870
ESC Complaints 333‑076‑0880
ESC Investigations 333‑076‑0890
ESC Health Care Practitioner Credentialing 333‑076‑0900
ESC Governing Body 333‑076‑0910
ESC Medical Staff 333‑076‑0920
ESC Personnel 333‑076‑0930
ESC Policies and Procedures 333‑076‑0940
ESC Admission Criteria, Patient Care and Discharge 333‑076‑0950
ESC Patient Transfer 333‑076‑0960
ESC Nursing Services 333‑076‑0970
ESC Pharmacy Services 333‑076‑0980
ESC Laboratory Services 333‑076‑0990
ESC Radiologic Services 333‑076‑1000
ESC Dietary Services 333‑076‑1010
ESC Medical Records 333‑076‑1020
ESC Quality Assessment and Performance Improvement 333‑076‑1030
ESC Infection Control 333‑076‑1040
ESC Data Collection and Reporting 333‑076‑1050
ESC Physical Environment 333‑076‑1065
ESC Waivers 333‑076‑1070
ESC Violations 333‑076‑1080
ESC Informal Enforcement 333‑076‑1090
ESC Formal Enforcement 333‑076‑1100
ESC Civil Penalties
Last Updated

Jun. 8, 2021

Rule 333-076-0165’s source at or​.us