Oregon Administrative Rules › Chapter 333 - OREGON HEALTH AUTHORITY, PUBLIC HEALTH DIVISION › Division 76 - AMBULATORY SURGICAL CENTERS (ASC) AND EXTENDED STAY CENTERS (ESC) › Section 333-076-0165 - ASC Medical Records

Current through Register Vol. 63, No. 7, July 1, 2024
(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;
			 and
(s) Such signed documents as
			 may be required by law.