Or. Admin. Code § 411-086-0300 - Clinical Records
(1) Clinical
Records Department. The facility shall ensure the preparation, completeness,
accuracy, preservation, and filing of a clinical record for each resident in
accordance with facility policy (OAR
411-085-0210). This rule does
not apply to nonmedical records.
(2) Director. The facility shall designate in
writing a staff person to function as clinical records coordinator who shall
ensure compliance with this rule. Services of a qualified medical record
consultant (RRA or ART) shall be provided as needed.
(3) Staffing, Equipment. There shall be
personnel, space, and equipment to provide efficient, systematic processing of
clinical records including but not limited to reviewing, indexing, filing, and
prompt retrieval.
(4) Filing. A
system of identification and filing to ensure the rapid location of resident
clinical records shall be maintained. A resident master index containing at
least the full name of each resident, date of birth, clinical record number as
applicable, date of admission, date of discharge, legal representative and
physician of record shall be maintained.
(5) Content of Clinical Record. A clinical
record shall be maintained for each resident. Each record shall contain
supporting data, written in sequence of events to justify the diagnosis and
warrant the treatment and results. All entries shall be kept current, accurate,
dated and signed. All clinical records shall be either typewritten or recorded
legibly in ink and shall include but not be limited to the following
information:
(a) Admitting diagnosis and
identification data including the resident's name, previous address, date and
time of admission, sex, date of birth, marital status, religious preference and
social security number; name, address, and telephone number of nearest relative
or personal agent; place admitted from; attending physician; alternate
physician (clinic or service); dentist; legal representative and RN care
manager;
(b) A medical history and
physical exam or medical summary as to the resident's condition which is signed
by a physician. If a resident is re-admitted within 30 days for the same
condition, the previous history and physical or medical summary, with an
interval note signed by a physician, will suffice. If an ongoing clinical
record is maintained in a comprehensive care facility, it may be used if
accompanied by a physical exam report completed within the previous 30
days;
(c) Clinical reports,
current, dated, and signed. Such reports include, but are not limited to,
laboratory, x-ray, and results of tests/exams including those for communicable
diseases;
(d) Physician's orders,
current, dated and signed;
(e)
Physician's progress notes dated and signed;
(f) Timely, written, dated, pertinent,
complete and signed clinical observations. Clinical observations shall include
changes in condition, results of treatments and medications, and unusual
events. Clinical observations shall include outcome of the resident care plan
and shall be summarized by nursing staff at least quarterly unless the
resident's condition dictates otherwise;
(g) Record of medication administration
including name of drug, dosage, frequency, mode of administration, date, time
and signature of the person administering medication. Documentation shall also
include, when applicable, site of injection, reaction, reason for withholding
any medication, and reason for administering any "prn" (as needed)
medication;
(h) Record of
treatments administered which shall be dated, timed and signed by those
performing treatments;
(i)
Miscellaneous items such as releases, consent forms, mortician's receipts,
valuables list and medical correspondence as applicable;
(j) Discharge summary prepared in accordance
with OAR 411-086-0160 and signed by the
attending physician. The summary shall include admitting diagnosis/reason for
admission, summary of the course of treatment in the facility, final diagnosis
with a follow-up plan if appropriate, condition on discharge or cause of death;
and
(k) The "Directive to
Physicians" ("Living Will"), the Power of Attorney for Health Care and similar
legal documents regarding resident care directives, if any, shall be filed in
the resident's clinical record in a manner which makes them prominent and
conspicuous.
(6) Record
Retention. All clinical records shall be kept for a period of five years after
the date of last discharge of the resident. A clinical record for each resident
for whom care has been provided in the previous six months shall be immediately
available for review by Division representatives upon request.
(7) Resident Transfer. When a resident is
transferred to another facility, the following information shall accompany the
resident:
(a) The name of the facility from
which transferred;
(b) The names of
attending physicians prior to transfer;
(c) The name of physician to assume
care;
(d) The date and time of
discharge;
(e) Most recent history
and physical;
(f) Current
diagnosis, orders from a physician for immediate care of the resident, nursing,
and other information germane to the resident's condition;
(g) A copy of the discharge summary. If the
discharge summary is not available at time of transfer, it shall be transmitted
as soon as available, but no later than seven days after transfer;
and
(h) A copy of the current
Directive and Power of Attorney for Health Care, if any.
(8) Ownership of Records. Clinical records
are the property of the licensee. The clinical record, either in original or
microfilm form, shall not be removed from the control of the facility except
where necessary for a judicial or administrative proceeding. Authorized
representatives of the Division shall be permitted to review and obtain copies
of clinical records as necessary to determine compliance with OAR 411:
(a) If a facility changes ownership all
clinical records in original or microfilm form shall remain in the facility and
ownership shall be transferred to the new licensee;
(b) In the event of dissolution of a
facility, the administrator shall ensure that clinical records are transferred
to another health care facility or to the resident's primary care physician,
and shall notify the Division as to the location of each clinical record. The
party to whom the records are transferred must have agreed to serve as
custodian of the records.
Notes
Stat. Auth.: ORS 410.070, 410.090 & 441.055
Stats. Implemented: ORS 441.055 & 441.615
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