OAR 333-076-0690
Birthing Centers: Health and Medical Records

Health and Clinical Records must be developed according to procedures outlined in the Policy and Procedures Manual as a legal record and an instrument for the continuity of care and must include:

(1)

Contents — The records of each client must contain:

(a)

Demographic data, initial prenatal physical examination, laboratory tests and evaluation of risk status;

(b)

Continuous periodic prenatal examination and evaluation of risk status;

(c)

A signed informed consent (refer also to OAR 333-076-0670 (Birthing Centers: Policies and Procedures)(12));

(d)

History, physical examination and risk assessment on admission to the Center in labor (including assessment of mother and fetus);

(e)

Continuous assessment of the mother and fetus during labor and delivery;

(f)

Labor summary;

(g)

The emergency transport plan for the client;

(h)

Physical assessment of newborn, including Apgar scores and vital signs;

(i)

Post partum evaluation of the mother;

(j)

Discharge summary for mother and newborn;

(k)

Documentation of consultation, referral, and/or transfer;

(l)

Signed documents as may be required by law; and

(m)

Records of newborn and stillborn infants must include, in addition to the requirement for medical records, the following information:

(A)

Date and hour of birth, birth weight and length of infant, period of gestation, sex, and condition of infant on delivery;

(B)

Mother’s name;

(C)

Record of ophthalmic prophylaxis and Vitamin K administration or refusal of same; and

(D)

Progress notes including:
(i)
Temperature, weight and feeding data;
(ii)
Number, consistency and color of stools;
(iii)
Urinary output;
(iv)
Condition of eyes and umbilical cord;
(v)
Condition and color of skin; and
(vi)
Motor behavior.

(2)

All entries in a client’s labor record must be dated, timed, and authenticated. Verification of an entry requires use of a unique identifier, i.e., signature, code, thumbprint, voice print or other means, that allows identification of the individual responsible for the entry.

(3)

A single signature or authentication of the responsible practitioner on the clinical record does not suffice to cover the entire content of the record.

(4)

The completion of the clinical record must be the responsibility of the attending practitioner.

(5)

The Center will ensure that the prenatal and intrapartal records are available at the time of admission and in the event of transfer to the care of another clinician or health care facility.

(6)

Storage — The records will be stored in such a way as to minimize the chance of their destruction by fire or other source of loss or damage and to ensure prevention of access by unauthorized persons.

(7)

Records are the property of the Center, and will be kept confidential unless released by the permission of the client. An exception is that they may be reviewed by representatives of the Division, and will be provided in copy form to such representatives on request.

(8)

All clinical records must be kept for a period of at least twenty-one years after the date of last discharge. Original clinical records may be retained on paper, microfilm, electronic or other media.

(9)

If a Center changes ownership all clinical records in original, electronic, or microfilm form must remain in the Center, and it must be the responsibility of the new owner to protect and maintain these records.

(10)

If a Birthing Center must be closed, its clinical records may be delivered and turned over to any other health care facility in the vicinity willing to accept and maintain the same as provided in section (8) of this rule.

(11)

If a qualified clinical record practitioner, RHIA (Registered Health Information Administrator) or RHIT (Registered Health Information Technician) is not the Director of the Clinical Records Department, the Division may require the Center to obtain periodic and at least annual consultation from a qualified clinical records consultant, RHIA/RHIT. The visits of the clinical records consultant must be of sufficient duration and frequency to review clinical record systems and assure quality records of the clients. Contract for such services must be available to the Division.

Source: Rule 333-076-0690 — Birthing Centers: Health and Medical Records, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=333-076-0690.

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 333-076-0690’s source at or​.us