Oregon Oregon Health Authority, Public Health Division
(1) A medical record shall be maintained for every patient admitted for care in a hospital.(2) A legible reproducible medical record shall include, but is not limited to (as applicable):(a) Admitting identification data including date of admission.(b) Chief complaint.(c) Pertinent family and personal history.(d) Medical history, physical examination report and provisional diagnosis as required by OAR 333-510-0010 (Patient Admission and Treatment Orders).(e) Admission notes outlining information crucial to patient care.(f) All patient admission, treatment, and discharge orders:(A) All patient orders shall be initiated, dated, timed and authenticated by a licensed health care practitioner in accordance with section (7) of this rule.(B) Documentation of verbal orders shall include:(i) The date and time the order was received;(ii) The name and title of the health care practitioner who gave the order; and(iii) Authentication by the authorized individual who accepted the order, including the individual’s title.(C) Verbal orders shall be dated, timed, and authenticated promptly by the ordering health care practitioner or another health care practitioner who is responsible for the care of the patient.(D) For purposes of this rule, a verbal order includes but is not limited to an order given over the telephone.(g) Clinical laboratory reports as well as reports on any special examinations. The original report shall be recorded in the patient’s medical record.(h) X-ray reports bearing the identification of the originator of the interpretation.(i) Consultation reports when such services have been obtained.(j) Records of assessment and intervention, including graphic charts and medication records and appropriate personnel notes.(k) Discharge planning documentation in accordance with OAR 333-505-0055 (Discharge Planning Requirements).(l) Discharge summary including final diagnosis.(m) Autopsy report if applicable.(n) Such signed documents as may be required by law.(o) Informed consent forms that document:(A) The name of the hospital 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 hospital has the capability to provide;(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;(p) Documentation of the disclosures required in ORS 441.098 (Health practitioner referral of patient to treatment or diagnostic testing facility); and(q) Documentation of support persons designated by a patient, or a patient’s legal representative, in collaboration with the patient, pursuant to OAR 333-505-0033 (Patient Rights). The following information shall be documented:(A) The name and contact information for each designated support person;(B) The date and time the patient was informed of their rights in OAR 333-505-0033 (Patient Rights)(3) to designate support persons and have one support person present at all times to assist the patient when the patient is receiving hospital services; and(C) Any conditions imposed on the support person(s). (3) A medical record of a surgical patient shall include, in addition to other record requirements, but is not limited to:(a) Preoperative history, physical examination and diagnosis documented prior to operation.(b) Anesthesia record including preanesthesia assessment and plan for anesthesia, records of anesthesia, analgesia and medications given in the course of the operation and postanesthetic condition.(c) 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. When the dictated operative report is not placed in the medical record immediately after surgery, an operative progress note shall be entered in the medical record after surgery to provide pertinent information for any individual required to provide care to the patient.(d) Postanesthesia recovery progress notes.(e) Pathology report on tissues and appliances, if any, removed at the operation.(4) An obstetrical record for a patient, in addition to the requirements for medical records, shall include but is not limited to:(a) The prenatal care record containing at least a serologic test result for syphilis, Rh factor determination, and past obstetrical history and physical examination.(b) The labor and delivery record, including reasons for induction and operative procedures, if any.(c) Records of anesthesia, analgesia, and medications given in the course of delivery.(5) A medical record of a newborn or stillborn infant, in addition to the requirement for medical records, shall include but is not limited to:(a) Date and hour of birth; birth weight and length; period of gestation; sex; and condition of infant on delivery (Apgar rating is recommended).(b) Mother’s name and hospital number.(c) Record of ophthalmic prophylaxis or refusal of same.(d) Physical examination at birth and at discharge.(e) Progress and nurse’s notes including temperature; weight and feeding data; number, consistency and color of stools; urinary output; condition of eyes and umbilical cord; condition and color of skin; and motor behavior.(f) Type of identification placed on infant in delivery room.(g) Newborn hearing screening tests conducted in accordance with OAR chapter 333, division 20.(6) A patient’s emergency room, outpatient and clinic records, in addition to the requirements for medical records, shall be maintained and available to the other professional services of the hospital and shall include but are not limited to:(a) Patient identification.(b) Admitting diagnosis, chief complaint and brief history of the disease or injury.(c) Physical findings.(d) Laboratory and X-ray reports (if performed), as well as reports on any special examinations. The original report shall be authenticated and recorded in the patient’s medical record.(e) Diagnosis.(f) Record of treatment, including medications.(g) Disposition of case with instructions to the patient.(h) Signature or authentication of attending physician.(i) A record of the pre-hospital report form (when patient is brought in by ambulance) shall be attached to the emergency room record.(7) All entries in a patient’s medical record shall be dated, timed and authenticated.(a) Authentication of an entry requires the use of a unique identifier, including but not limited to a written signature or initials, code, password, or by other computer or electronic means that allows identification of the individual responsible for the entry.(b) Systems for authentication of dictated, computer, or electronically generated documents must ensure that the author of the entry has verified the accuracy of the document after it has been transcribed or generated.(8) The following records shall be maintained in written or computerized form for the time period specified:(a) Permanent:(A) Patient’s register, containing admissions and discharges;(B) Patient’s master index;(C) Register of all deliveries, including live births and stillbirths;(D) Register of all deaths; and(E) Register of operations.(b) Seven years:(A) Register of outpatients; and(B) Emergency room register.(c) Blood banking register shall be retained for 20 years.(9) The completion of the medical record shall be the responsibility of the attending qualified member of the medical staff. Any licensed health care practitioner responsible for providing or evaluating the service provided shall complete and authenticate those portions of the record that pertain to their portion of the patient’s care. The appropriate individual shall authenticate the history and physical examination, operative report, progress notes, orders and the summary. In a hospital using interns, such orders must be according to policies and protocols established and approved by the medical staff. An authentication of a licensed health care practitioner on the face sheet of the medical record does not suffice to cover the entire content of the record:(a) Medical records shall be completed by a licensed health care practitioner and closed 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 is not limited to:(A) The name of the hospital from which they were transferred;(B) The name of physician or other health care practitioner to assume care at the receiving facility;(C) The date and time of discharge;(D) The current medical findings;(E) The current nursing assessment;(F) Current medical history and physical information;(G) Current diagnosis;(H) Orders from a physician or other licensed health care practitioner for immediate care of the patient;(I) Operative report, if applicable;(J) TB test, if applicable; and(K) Other information germane to patient’s condition.(c) If the discharge summary is not available at time of transfer, it shall be transmitted to the new facility as soon as it is available.(10) Diagnoses and operations shall be expressed in standard terminology. Only abbreviations approved by the medical staff may be used in the medical records.(11) Medical records shall be filed and indexed. Filing shall consist of an alphabetical master file with a number cross-file. Indexing is to be done according to diagnosis, operation, and qualified member of the medical staff, using a system such as the International or Standard nomenclature systems.(12) Medical records are the property of the hospital. The medical record, either in original, electronic or microfilm form, shall not be removed from the hospital except where necessary for a judicial or administrative proceeding. Treating and attending physicians shall have access to medical records. When a hospital uses off-site storage for medical records, arrangements must be made for delivery of these records to the hospital when needed for patient care or other hospital activities. Precautions must be taken to protect patient confidentiality.(13) Authorized personnel of the Division shall be permitted to review medical records and patient registers as necessary to determine compliance with health care facility licensing laws.(14) Medical records shall be kept for a period of at least 10 years after discharge. Original medical records may be retained on paper, microfilm, electronic or other media.(15) Medical records shall be protected against unauthorized access, fire, water and theft.(16) If a hospital changes ownership, all medical records in original, electronic or microfilm form shall remain in the hospital and it shall be the responsibility of the new owner to protect and maintain these records.(17) If a hospital closes, its medical records and the registers required under section (8) of this rule may be delivered and turned over to any other hospital in the vicinity willing to accept and retain the same as provided in section (12) of this rule. A hospital which closes permanently shall follow the procedure for Division and public notice regarding disposal of medical records under OAR 333-500-0060 (Return of Hospital License and Hospital Closure).(18) 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 a patient’s last exam date if professional interpretations of such graphics are included in the medical records. Mammography images shall be retained for 10 years after a patient’s last exam date.(19) If a qualified medical record practitioner, RHIT (Registered Health Information Technician) or RHIA (Registered Health Information Administrator) is not the Director of the Medical Records Department, periodic and at least annual consultation must be provided by a qualified medical records consultant, RHIT or RHIA. 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. The contract for such services shall be made available to the Division.(20) A current written policy on the release of medical record information including a patient’s access to his or her medical record shall be maintained in the medical records department.(21) A hospital is not required to keep a medical record in accordance with this rule for a person referred to a hospital ancillary department for a diagnostic procedure or health screening by a private physician, dentist, or other licensed health care practitioner acting within his or her scope of practice.(22) Pursuant to ORS 441.059 (Access to previous X-rays and reports by patients of chiropractic physicians), the rules of a hospital that govern patient access to previously performed X-rays or diagnostic laboratory reports shall not discriminate between patients of chiropractic physicians and patients of other licensed health care practitioners permitted access to such X-rays and diagnostic laboratory reports.(23) Nothing in this rule is meant to prohibit or discourage a hospital from maintaining its records in electronic form.