Or. Admin. Code § 166-150-0065

Current through Register Vol. 63, No. 12, December 1, 2024

Section 166-150-0065 - County Health - Public/Community Health Records

(1)Alcohol and Drug Service Records Series documents services provided to clients in alcohol and drug treatment programs. These services may include residential treatment and care, outpatient services, detoxification, DUII education and treatment, sex offender treatment, methadone treatment, and other services. Series may consist of clinical records or patient files including assessment records, treatment plans, progress notes, treatment reviews, termination reports, and medical records. (Minimum retention: 6 years after last service or until 21st birth-day, whichever is longer)

(2) Board of Health Reports Series documents the activities of the county health departments such as public or community health, mental health, environmental health, family mediation, alcohol and drug, developmental disabilities, deputy medical examiner, and fiscal administration. Series includes semi-annual reports to the County Board of Health prepared by the various departments. The reports summarize department activities, and discuss concerns and problems of future importance. Series may also contain reports on special topics such as AIDS and other issues. Reports may be sent to the Board of County Commissioners. (Minimum retention:

(a) Reports filed with County Commissioners: 10 years

(b) Reports not filed with County Commissioners: Permanent)

(3) Car Seat Rental Service Records Series documents the rental of car seats for infants and young children. Information contained in the records may include name, weight, and date of birth of child; name and address of recipient; signatures; witnesses; conditions for loan; car seat number; and related documentation. (Minimum reten-tion:

(a) If car seat returned: Until return of car seat

(b) If car seat is not returned: 5 years)

(4)Communicable Disease Intake Report Series is used to identify persons with communicable diseases such as sexually transmitted diseases, HIV, tuberculosis, food-borne diseases, and others. Information contained in the report may include name of disease, patient identification, name of physician, symptoms, laboratory results, and other related data. Information from this intake report may be transferred to the investigation report or the intake report may be attached to the investigation report. (Minimum retention: 1 year)

(5)Communicable Disease Investigation Reports Series documents investigations into reports of communicable diseases. The investigation form is used by nurses to compile information about persons with a communicable disease. Information contained in the investigation reports (there are forms for different diseases) may include patient identification; demographics; sources of report; basis of diagnosis including clinical data, laboratory data and report, and epi-linkage; infection timeline indicating exposure and communicable periods; and other related data. The Notice of a Disease or Condition form may contain disease, patient identification, date of onset of disease, names and addresses of physician and person reporting, and other related data. Copies of both forms are sent to the Oregon Health Division. (Minimum retention:

(a) Investigation Form: 5 years

(b) Notice of a Disease or Condition Form: 3 years)

(6) Communicable Disease Log Series documents communi-cable diseases by providing a summary of information taken from the intake report. Information contained in the log may include type of disease, patient name, date of report, and other related data. Series is used for quick reference and to compile statistics. (Minimum retention: 5 years)

(7)Complaint Correspondence Records document formal and informal complaints involving extended investigation and/or litigation concerning environmental health issues; staff or division policies; or other perceived health problems in the community. Records may include letters, memorandum, hearing transcripts, Board of County Commissioner minutes, and other records which document or add significant information to the complaint. (Minimum retention: 10 years after resolution)

(8)Health Insurance Portability and Accountability Act (HIPAA) Disclosure Notices Records document notification to clients about the agency's practices regarding client medical records and information under HIPAA. Records include notification forms and related records. (Minimum retention: 6 years after last service)

(9)HIV Test Records Series documents the results of anony-mous or confidential HIV tests. Information contained in the records may include test results, demographic information, patient history, number of test results, and other related data. Anonymous testing programs do not give the name of the patient, and may include only a client number and demographic information such as race, age, and sex. Confidential programs include the name and address of the patient which is then kept confidential. (Minimum retention: 2 years)

(10)Immunization and Injection Records Series documents immunizations received by a patient. Services may include immunizations for infants, children, and adults; TB skin tests; flu and pneumonia shots; and overseas immunizations for travelers. Information contained in the records may include name and date of birth of patient; name, address, and phone number of parent/ guardian; type of vaccine; dose number; date; and other related data. Records may include ITARS (Immunization Tracking and Recall System) documentation. (Minimum reten-tion:

(a) Immunization records: 10 years

(b) ITARS records: 25 years from date of last service

(c) Other records: 6 years after last service or until 21st birthday, whichever is longer)

(11)Immunization Authorization Records Series documents authorizations and parental/guardian consent for children and other patients to receive immunizations. Information contained in the records may include name and address of person receiving immunization; name and signature of patient or parent/guardian; date vaccinated; manufacturer and lot number of vaccine; site of injection; signature of provider; and other related data. (Minimum retention: 10 years)

(12)Immunization Cards Series used to enter information about immunizations given to clients in the county's immunization database. Information includes type of vaccine, PPD results, and a clients contraindications of precautions regarding a specific vaccine. Vaccines include Measles, Mumps, Rubella; Dipheria/Pertussis/Tetanus; Polio; Immune Globulin; Hepatitis A; Hepatitis B; Haemophilus Influenza Type B; Influenza; Pneumococcal; and Varicella. (Minimum retention: Until entered into system and verified)

(13)Interpreter Service Records Series documents the scheduling of interpreters for needed county departments, and the services provided for payment purposes. Records may include interpreter scheduling and request forms, on-call invoices, timesheets, and related records. (Minimum retention: 2 years)

(14)Laboratory Logs Series documents laboratory tests per-formed for patients. Types of laboratory tests may include hematocrits, urinalysis, GC cultures, wet mounts, serologies, blood typing and Rh factor, and pregnancy tests. Information contained in the logs may include name of patient, date, name of test, results of test, date of results, name of person who performed the test, and other related data. (Minimum retention: 2 years)

(15)Maternal-Child Health (Children and Family) Service Referral Reports Series documents referrals involving maternal-child health concerns from other providers, such as physicians or hospitals. Information contained in the reports may include the name and address of the family; name and age of child; reason for referral; history and concerns; and any actions or services provided by the referral agency. If services are provided to the patient, the referral report becomes part of the Public Health Service Records. (Minimum retention:

(a) If services provided: Transfer to Public Health Service Records

(b) All other cases: 2 years)

(16)Medicaid Financial Screening Records Series documents the screening of clients who appear eligible for Medicaid for a final eligibility determination by Adult and Family Services (AFS). Records contained in the series include Medicaid Financial Screening Form, which indicates the client's income status, lists of clients, and AFS forms which indicate the client's personal data as it applies to eligibility, client's understanding of rights and responsibilities, effective date of eligibility pending client's provision of appropriate documentation, narrative notes completed by screeners, information on insurance already held by client, and information relating to injuries caused by automobile accidents. (Minimum retention: 2 years)

(17)Medical Examiner Case Files Series documents investigations into deaths by the county medical examiner, coroner, or other designated official. Series contains records on any deceased person that requires medical examiner involvement. Records include the autopsy report and the medical examiners report. Records may also include other data that is considered significant as to the manner of death such as a police report, family interview, personal identification, and disposition of unclaimed funds. (Minimum retention:

(a) Pre-1965 Coroner's Reports: Permanent

(b) Post-1965 case files: 25 years

(c) No case file developed: 5 years)

(18)Pharmacy Logs Series documents the dispensing or issuing of drugs such as birth control pills or antibiotics. Information contained in the log may include identification number, client name, date, name of drug, dosage, number of pills, initials of person dispensing the drug, and other related data. (Minimum retention: 3 years)

(19) Public Health Service Index (Master Patient Index) Cards Series provides an index to patients and the services provided to them. Information contained in the index may include patient name, address, and birthdate; services provided; program; first date of service; dates admitted and discharged; health record number; and other related data. Separate indexes may be kept for different programs. (Minimum retention: 25 years after date of last service)

(20)Public Health Service Records Series documents the services given to a patient. Series contains records for patients in specialized programs such as the Women, Infants, and Children (WIC) nutrition program; clinical services (including tuberculosis, HIV, sexually transmitted diseases, hepatitis, and immunizations); dental services; sero-wellness; family planning and pregnancy testing; car-seat rental; maternal-child health nursing services concerning high risk pregnancies, high risk infants, or young children with major health problems or disabilities; and public health field nursing services which may include counseling, teaching, and referral services concerning maternal and child health care, pregnancy and postpartum health, child development, parenting skills, and Sudden Infant Death Syndrome (SIDS). Series may include correspondence; reports; professional notations; laboratory reports; treatment and x-ray authorizations; release of information; clinical or medical records including client identification, progress notes, and records of visits; and other related data. (Minimum retention:

(a) Outpatient physical therapy and speech-language pathology service records: 6 years after last service or until 21st birthday, whichever is longer

(b) Dental patient records: 7 years after last service

(c) All other outpatient service records: 6 years after last service

(d) Counties participating in the Medicare Advantage Program, retain all records 10 years after contract expires (42CFR 422.504)

(21)Sero-Positive Wellness Program Charts Series documents the services and treatment provided to people with HIV. Information contained in the charts may include a record of service and treatment, laboratory results, work plans, and other related data. The records are used for counseling and education purposes. The records may be transferred to the Oregon Health Division upon closure, or they may become part of the patient's clinical file in the Public Health Service Records. (Minimum retention: 6 years after last service)

(22)Sexually Transmitted Disease Epidemiological Reports Series documents the investigation into sexually transmitted diseases. Information is compiled on two forms. The Confidential Sexually Transmitted Disease Case Report contains information such as patient identification; diagnosis, site, and treatment of disease; provider name and address; and other related data. The Field Report (a form provided by the U.S. Department of Health & Human Services) contains information such as patient identification; exposure, referral, examination, and treatment information; interview notes; and other identifying or medical information. Copies of both records may be forwarded to the Oregon Health Division. Individuals who are seen and treated at STD clinics will have a clinical file in the Public Health Service Records. (Minimum retention:

(a) If patient is treated: transfer to Public Health Service Records

(b) If patient is not treated: 5 years)

(23)Tuberculosis Client Records (Tuberculosis Registry) Series documents patients with active and inactive cases of tuberculosis. Records may contain information such as patient identification; source of specimen; drug treatment information such as dosage and dates; dates the case was opened and closed; epidemiological reports; and other related data. (Minimum retention:

(a) Active cases where death date is known: retain for life of individual

(b) Active cases where death date is unknown: retain for 70 years after last service

(c) Inactive cases with patients on preventive drug therapy: 6 years after last service)

(24)Tuberculosis Negative Cases Epidemiological Reports Series documents service to patients with negative tuberculosis tests, that is, patients with positive skin tests who do not have the disease and have not received treatment. Information contained in the reports may include patient name, date, x-ray report, skin text results, and other related data. (Minimum retention: 2 years; destroy reports when recorded in Tuberculosis Client Records (Registry))

(25)Tuberculosis X-Ray Authorization Records Series documents authorizations and parental consent for children and other patients to receive tuberculosis x-rays. Information contained in the records may include patient identification, demographics, PPD test results, name of radiology lab, and related documentation. (Minimum retention: 6 years after last service)

(26)Tuberculosis X-Ray Records Series documents x-rays used to screen and diagnose cases of tuberculosis. Records may include registration cards and x-ray film. Information contained in the records may include patient identification, demographics, medical history, x-ray results, assessment of condition, treatment plan, drugs ordered, and related documentation. (Minimum retention:

(a) Active cases where death date is known: Retain for life of individual

(b) Active cases where death date is unknown: Retain for 70 years after last service

(c) Inactive cases with patients on preventive drug therapy: 6 years after last service)

Or. Admin. Code § 166-150-0065

OSA 4-2004, f. & cert. ef. 9-1-04; OSA 5-2006, f. & cert. ef. 12-15-06

Stat. Auth.: ORS 192 & 357

Stats. Implemented: ORS 192.005-192.170 & 357.805-357.895