Oregon Administrative Rules › Chapter 411 - DEPARTMENT OF HUMAN SERVICES, AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES › Division 86 - NURSING FACILITIES/LICENSING - ADMINISTRATION AND SERVICES › Section 411-086-0300 - Clinical Records

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Clinical
			 Records Department. The facility shall ensure the preparation, completeness,
			 accuracy, preservation, and filing of a clinical record for each resident in
			 accordance with facility policy (OAR
			 411-085-0210). This rule does
			 not apply to nonmedical records.
(2) Director. The facility shall designate in
			 writing a staff person to function as clinical records coordinator who shall
			 ensure compliance with this rule. Services of a qualified medical record
			 consultant (RRA or ART) shall be provided as needed.
(3) Staffing, Equipment. There shall be
			 personnel, space, and equipment to provide efficient, systematic processing of
			 clinical records including but not limited to reviewing, indexing, filing, and
			 prompt retrieval.
(4) Filing. A
			 system of identification and filing to ensure the rapid location of resident
			 clinical records shall be maintained. A resident master index containing at
			 least the full name of each resident, date of birth, clinical record number as
			 applicable, date of admission, date of discharge, legal representative and
			 physician of record shall be maintained.
(5) Content of Clinical Record. A clinical
			 record shall be maintained for each resident. Each record shall contain
			 supporting data, written in sequence of events to justify the diagnosis and
			 warrant the treatment and results. All entries shall be kept current, accurate,
			 dated and signed. All clinical records shall be either typewritten or recorded
			 legibly in ink and shall include but not be limited to the following
			 information:
(a) Admitting diagnosis and
			 identification data including the resident's name, previous address, date and
			 time of admission, sex, date of birth, marital status, religious preference and
			 social security number; name, address, and telephone number of nearest relative
			 or personal agent; place admitted from; attending physician; alternate
			 physician (clinic or service); dentist; legal representative and RN care
			 manager;
(b) A medical history and
			 physical exam or medical summary as to the resident's condition which is signed
			 by a physician. If a resident is re-admitted within 30 days for the same
			 condition, the previous history and physical or medical summary, with an
			 interval note signed by a physician, will suffice. If an ongoing clinical
			 record is maintained in a comprehensive care facility, it may be used if
			 accompanied by a physical exam report completed within the previous 30
			 days;
(c) Clinical reports,
			 current, dated, and signed. Such reports include, but are not limited to,
			 laboratory, x-ray, and results of tests/exams including those for communicable
			 diseases;
(d) Physician's orders,
			 current, dated and signed;
(e)
			 Physician's progress notes dated and signed;
(f) Timely, written, dated, pertinent,
			 complete and signed clinical observations. Clinical observations shall include
			 changes in condition, results of treatments and medications, and unusual
			 events. Clinical observations shall include outcome of the resident care plan
			 and shall be summarized by nursing staff at least quarterly unless the
			 resident's condition dictates otherwise;
(g) Record of medication administration
			 including name of drug, dosage, frequency, mode of administration, date, time
			 and signature of the person administering medication. Documentation shall also
			 include, when applicable, site of injection, reaction, reason for withholding
			 any medication, and reason for administering any "prn" (as needed)
			 medication;
(h) Record of
			 treatments administered which shall be dated, timed and signed by those
			 performing treatments;
(i)
			 Miscellaneous items such as releases, consent forms, mortician's receipts,
			 valuables list and medical correspondence as applicable;
(j) Discharge summary prepared in accordance
			 with OAR 411-086-0160 and signed by the
			 attending physician. The summary shall include admitting diagnosis/reason for
			 admission, summary of the course of treatment in the facility, final diagnosis
			 with a follow-up plan if appropriate, condition on discharge or cause of death;
			 and
(k) The "Directive to
			 Physicians" ("Living Will"), the Power of Attorney for Health Care and similar
			 legal documents regarding resident care directives, if any, shall be filed in
			 the resident's clinical record in a manner which makes them prominent and
			 conspicuous.