333-071-0430 Medical Records (1) A medical record shall be maintained for every patient admitted for care in an SICF. (2) A legible reproducible medical record shall include, but is not limited to the following (if 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 333-071-0470. (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 (4) 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 authenticated and 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 summary including final diagnosis. (L) Discharge order. (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 SICF 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 SICF 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. (3) In addition to the requirements specified in section (2) of this rule, the following information shall be transferred to and made part of the SICF patient medical record, if applicable: (a) Surgical records: (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. (b) Obstetrical records: (A) The patient's prenatal care including 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. (c) Emergency room, outpatient and clinic records: (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. (4) 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. (5) The following records shall be maintained and kept permanently in written or computerized form: (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 outpatients (seven years). (6) 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 services 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 facility 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 includes but is not limited to: (A) The name of the facility from which the patient was 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; (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 available. (7) Diagnoses and operations shall be expressed in standard terminology. Only abbreviations approved by the medical staff may be used in the medical records. (8) 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. (9) Medical records are the property of the SICF. An SICF shall comply with the use, disclosure, protection and security requirements of the federal Health Insurance Portability and Accountability Act of 1996 (P.L.104-191) and regulations adopted under that law, including 45 CFR parts 160 and 164, federal alcohol and drug treatment confidentiality laws and regulations adopted under those laws, including 42 CFR part 2, and state health and mental health confidentiality laws, including ORS 179.505, 192.517 and 192.553 to 192.581. (10) Authorized personnel of the Authority shall be permitted to review medical records and patient registers as necessary to determine compliance with SICF licensing laws. (11) 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, electronic or other media. (12) If an SICF changes ownership, all medical records in original or electronic form shall remain in the facility or related institution, and it shall be the responsibility of the new owner to protect and maintain these records. (13) If an SICF closes, its medical records and the registers required under section (5) of this rule may be delivered and turned over to any other facility in the vicinity willing to accept and retain the same as provided in section (11) of this rule. An SICF which closes permanently shall follow the procedure for Authority and public notice regarding disposal of medical records under OAR 333-071-0240. (14) 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 visit if professional interpretations of such graphics are included in the medical records. (15) 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/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 Authority. (16) 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. (17) Pursuant to ORS 441.059, the rules of an SICF 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. (18) Nothing in this rule is meant to prohibit or discourage an SICF from maintaining its records in electronic form . Statutory/Other Authority: ORS 441.025 Statutes/Other Implemented: ORS 441.025 History: PH 4-2019, amend filed 02/21/2019, effective 02/21/2019 PH 281-2018, renumbered from 333-071-0060, filed 12/19/2018, effective 12/19/2018 OHD 6-1999, f. & cert. ef. 10-22-99 HD 5-1989, f. 7-14-89, cert. ef. 8-1-89 HD 11-1988, f. & cert. ef. 5-27-88 HD 17-1987(Temp), f. 10-13-87, ef. 10-15-87 thru 4-15-88