Oregon Administrative Rules › Chapter 811 - BOARD OF CHIROPRACTIC EXAMINERS › Division 15 - CONSUMER PROTECTION › Section 811-015-0005 - Records

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Failure to keep
			 complete, accurate, and minimally competent records on all patients shall be
			 considered unprofessional conduct.
(a) Each
			 patient shall have exclusive records which shall be clear, legible, complete,
			 and accurate as to allow any other chiropractic physician to understand the
			 nature of that patient's case and to be able to follow up with the care of that
			 patient, if necessary.
(b) Every
			 page of chart notes will identify the patient by name and one other unique
			 identifier (date of birth, medical record number, etc.), and the clinic of
			 origin by name and address. Each entry will be identified by day, month, year,
			 provider of service, and author of the record.
(c) Clear, legible, complete, accurate, and
			 minimally competent records shall contain the following:
(A) A description of the chief complaint or
			 primary reason the patient sought treatment from the licensee.
(B) Documentation of any significant event
			 that affects the chief complaint of the patient or the general history of the
			 health of the patient.
(C) An
			 accurate record of the diagnostic and therapeutic procedures that the licensee
			 has employed in providing chiropractic services to the patient, including, but
			 not limited to:
(i) Height, weight, blood
			 pressure, and pulse at initial examination. If initial examination is via
			 telemedicine, record patient's height and weight by patient's report. Record
			 blood pressure and pulse if patient is able to obtain remotely. Height, weight,
			 blood pressure and pulse is recorded on subsequent visits, as clinically
			 indicated;
(ii) Examinations and
			 the results of those examinations;
(iii) Diagnoses;
(iv) Treatment plan, any subsequent changes
			 to the treatment plan, and the clinical reasoning for those changes;
(v) Dates on which the licensee provided
			 clinical services to the patient, as well as the services performed, and
			 clinical indications for those services;
(vi) Areas of the patient's body where the
			 licensee has provided care;
(vii)
			 Patient's response to treatment;
(viii) Therapeutic procedures must be clearly
			 described including information such as providers involved, timing, setting,
			 and tools used, as appropriate.
(D) Document written informed consent has
			 been obtained in the chart. Regarding informed consent and PARQ (Procedures,
			 Alternatives, Risks, and Questions) requirements, refer to OAR 811-035-0005 (2)(a) and (b).
(E) Other
			 clinically relevant correspondence, including, but not limited to: telephonic
			 or other patient communications, referrals to other practitioners, and expert
			 reports.
(d) A
			 chiropractic physician shall maintain billing records for services performed
			 for which payment is received from or billed to the patient, an insurance
			 company, or another person or entity who has assumed the financial
			 responsibility for the payment of services performed to the patient. Such
			 records will be maintained for the same amount of time as other patient
			 records. At a minimum, a billing record will include the date of the patient
			 encounter or financial entry, a notation of the services performed either by
			 description or code, common codes such as the AMA Current Procedural
			 Terminology (CPT) codes may be used without additional explanation or legend,
			 and the fee charged for the services billed. If third party payors are billed,
			 the billing instrument (CMS 1500 form or its successor) should be retrievable.
			 Such information may be maintained on a handwritten or printed ledger, with the
			 assistance of a computer or other device either by direct entry or with a
			 particular program or application, or by an alternative method. To the extent
			 billing records do not contain patient health care records not kept elsewhere,
			 they are not considered part of the clinical record.
(e) Such information as described in section
			 (d) must be readily available upon request of the patient, an agent of the
			 patient, an insurance carrier or entity responsible for the payment of the
			 services, or by the Board or other entity with a legal right to review such
			 information.