Oregon Administrative Rules › Chapter 333 - OREGON HEALTH AUTHORITY, PUBLIC HEALTH DIVISION › Division 700 - LICENSING STANDARDS FOR OUTPATIENT RENAL DIALYSIS FACILITIES › Section 333-700-0090 - Medical Records

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The facility
			 shall maintain complete medical records on all patients (including
			 self-dialysis patients within the self-dialysis unit and home dialysis patients
			 whose care is under the supervision of the facility) in accordance with
			 accepted professional standards and practices.
(2) The medical records must be completely
			 and accurately documented, readily available, and systematically organized to
			 facilitate the compilation and retrieval of information. Each patient's medical
			 record shall contain sufficient information to identify the patient clearly, to
			 justify the diagnosis and treatment, and to document the results accurately.
			 All medical records shall contain documented evidence of the following:
(a) Assessment of the needs of the
			 patient;
(b) Evidence that the
			 patient was informed of the results of the assessment;
(c) Documentation of any treatment with a
			 reprocessed hemodialyzer (when applicable);
(d) Establishment of an appropriate plan of
			 treatment;
(e) The care and
			 services provided;
(f)
			 Identification and social data;
(g)
			 Signed consent forms:
(A) All consent forms
			 shall document that the information was provided in such a way that
			 acknowledges the patient's individual language and special needs; and
(B) Except as provided in ORS 433.045, a
			 minor 15 years of age or older may consent to hospital care, medical or
			 surgical diagnosis or treatment by a physician, and dental care, without the
			 consent of a parent or guardian.
(h) Documentation of an initial history and
			 physical and an update of the history and physical at least annually or
			 whenever changes occur;
(i) Reports
			 of any pertinent medical, surgical or access procedures which shall be filed in
			 the record within 30 days of the procedure;
(j) Referral information with authentication
			 of diagnosis;
(k) Diagnostic and
			 therapeutic orders. Physician orders must be reviewed and rewritten annually.
			 "Resume previous orders" is not adequate to meet the annual requirement. All
			 verbal orders shall be received by a licensed nurse or physician associate.
			 Orders relating to social work or nutrition services may be received by the
			 professional responsible for that service. Verbal orders must be countersigned
			 within 45 calendar days by the practitioner giving the order. All patients
			 shall have written orders for length of dialysis treatment, the dialyzer type,
			 the composition of the dialysate, the estimated dry weight, any medications the
			 patient receives at the dialysis facility, the heparinization schedule
			 including the amount of the bolus, maintenance dose and when to discontinue the
			 maintenance dose, and any necessary infection control measures. New orders that
			 include, but are not limited to the above listed items, must be written when a
			 patient returns from an inpatient stay at a hospital;
(l) Progress notes;
(m) Reports of treatments and clinical
			 findings;
(n) Reports of laboratory
			 results, diagnostic tests, and procedures;
(o) Social worker and nutritional
			 assessments: Initial assessments must be completed within 30 days of admission
			 to the facility. Subsequent assessments must be completed annually and updated
			 as necessary; and
(p) A medication
			 list that is updated as needed and reviewed at least quarterly or as changes
			 occur.