Or. Admin. R. 847-017-0020 - Patient Medical Records
(1) A
legible, complete, comprehensive and accurate medical record must be maintained
for each patient evaluated or treated. The record must include:
(a) Identity of the patient;
(b) History and physical, diagnosis and
plan;
(c) Appropriate lab, x-ray or
other diagnostic reports;
(d)
Documentation of the PARQ conference ;
(e) Disclosure of the licensee 's specialty
board certification through the ABMS, the AOA-BOS, the ABPM, the ABFAS or the
NCCPA or lack thereof;
(f)
Appropriate preanesthesia evaluation;
(g) Narrative description of
procedure;
(h) Intraoperative and
postoperative monitoring;
(i)
Pathology reports;
(j)
Documentation of the outcome and the follow-up plan; and
(k) Provision for continuity of
post-procedure care.
(2)
If the office -based surgery is a Level II or Level III surgical procedure, the
patient record must include a separate anesthetic record that contains
documentation of anesthetic provider, ASA Physical Status , procedure, and
technique employed. This must include the type of anesthesia used, drugs (type
and dose) and fluids administered during the procedure, patient weight, level
of consciousness, estimated blood loss, duration of procedure, and any
complication or unusual events related to the procedure or
anesthesia.
(3) The patient record
must document if tissues and other specimens have been submitted for
histopathologic diagnosis.
(4) The
licensee must ensure that the facility has specific and current protocols in
place for patient confidentiality and security of all patient data and
information.
Notes
Statutory/Other Authority: ORS 677.265
Statutes/Other Implemented: ORS 677.085, ORS 677.097 & ORS 677.265
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