Oregon Administrative Rules › Chapter 333 - OREGON HEALTH AUTHORITY, PUBLIC HEALTH DIVISION › Division 71 - SPECIAL INPATIENT CARE FACILITIES › Section 333-071-0430 - 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 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.