Or. Admin. Code § 333-076-1010

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

Section 333-076-1010 - ESC Medical Records

(1) An ESC medical record shall be maintained for every patient admitted to the ESC for care that is separate and distinct from the affiliated ASC.

(2) Each ESC patient medical record shall be legible, reproducible and include at a minimum:

(a) A copy of the patient's medical record from the affiliated ASC meeting the requirements of OAR 333-076-0165(2);

(b) Laboratory and radiology test results;

(c) Medication and medical treatments;

(d) Progress notes;

(e) Nursing observation and assessment;

(f) Treatment plans;

(g) Discharge instructions and condition at discharge;

(h) Transfer documentation, if applicable;

(i) Documentation concerning advance directives, if any; and

(j) Signed discharge summary.

(3) ESC medical records shall be filed in a manner that renders them easily retrievable and shall be protected against unauthorized access, fire, water and theft.

(4) Medical records are the property of the ESC. The medical record, either in original, electronic or microfilm form, shall not be removed from the facility except where necessary for a judicial or administrative proceeding. Authorized personnel of the Authority shall be permitted to review medical records. When an ESC uses off-site storage for medical records, arrangements must be made for delivery of these records to the health care facility when needed for patient care or other health care facility activities. Precautions must be taken to protect patient confidentiality.

(5) All medical records shall be kept for a period of at least 10 years after the date of last discharge. Original medical records may be retained on paper, electronic or other media.

(6) If an ESC changes ownership all medical records in original, electronic or microfilm form shall remain in the ESC or related institution, and it shall be the responsibility of the new owner to protect and maintain these records.

(7) If any ESC shall be finally closed, its medical records may be delivered and turned over to any other health care facility in the vicinity willing to accept and retain the same as provided in section (5) of this rule.

(8) All original clinical records or photographic or electronic facsimile thereof, not otherwise incorporated in the medical record, such as X-rays, electrocardiograms, electroencephalograms, and radiological isotope scans shall be retained for seven years after patient's last discharge if professional interpretations of such graphics are included in the medical records.

(9) The Authority may require the facility to obtain periodic and at least annual consultation from a qualified medical records consultant, Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT). The visits of the medical records consultant shall be of sufficient duration and frequency to review medical record systems and assure quality records of the patients. Contract for such services shall be available to the Authority upon request.

Or. Admin. Code § 333-076-1010

PH 1-2019, adopt filed 01/07/2019, effective 1/7/2019

Statutory/Other Authority: ORS 441.025 & OL 2018 Chapter 50

Statutes/Other Implemented: ORS 441.025 & OL 2018 Chapter 50