Oregon Administrative Rules › Chapter 333 - OREGON HEALTH AUTHORITY, PUBLIC HEALTH DIVISION › Division 505 - HOSPITAL ORGANIZATION AND MANAGEMENT › Section 333-505-0050 - 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 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.
(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.
(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; 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. 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(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).