Or. Admin. Code § 333-076-0165

Current through Register Vol. 63, No. 11, November 1, 2024

Section 333-076-0165 - ASC Medical Records

(1) A medical record shall be maintained for every patient admitted for care.

(2) A legible reproducible medical record shall include at least the following (if applicable):

(a) Admitting identification data including date of admission;

(b) Chief complaint;

(c) Pertinent family and personal history;

(d) History and physical. This history and physical shall be completed no more than 30 days prior to the initiation of any procedure. Sufficient time shall be allowed between examination and the initiation of any procedure, to permit review of tests;

(e) Clinical laboratory reports as well as reports on any special examinations. (The original report shall be authenticated and recorded in the patient's medical record.);

(f) X-ray reports shall be recorded in the medical record and shall bear the identification (authentication) of the originator of the interpretation;

(g) Signed or authenticated report of consultant when such services have been obtained;

(h) All entries in patient's medical record must be dated, timed, and authenticated:

(A) Verification of an entry requires use of a unique identifier, for example, signature, code, thumbprint, voice print or other means, which allows identification of the individual responsible for the entry;

(B) Verbal orders may be accepted by those individuals authorized by law and by medical staff rules and regulations and shall be countersigned or authenticated within two business days by the ordering health care practitioner or another health care practitioner who is responsible for the care of the patient;

(C) A single signature or authentication of the physician, dentist, podiatrist or other individual authorized within the scope of his or her professional license on the medical record does not suffice to cover the entire content of the record.

(i) Records of assessment and intervention, including but not limited to preprocedure vital sign records, graphic charts, medication records and appropriate personnel notes;

(j) Anesthesia record including records of anesthesia, analgesia and medications given in the course of the operation and postanesthetic condition, signed or authenticated by the person making the entry;

(k) A record of operation dictated or written immediately following surgery and including a complete description of the operation procedures and findings, postoperative diagnostic impression, and a description of the tissues and appliances, if any, removed;

(l) Postanesthesia Recovery (PAR) progress notes including but not limited to vital sign records and other appropriate clinical notes;

(m) Pathology report on tissues and appliances, if any, removed at the operation. The following tissues and appliances may be exempted from pathology exam:

(A) Specimens that, by their nature or condition, do not permit fruitful examination, including but not limited to a cataract, orthopedic appliance, foreign body, or portion of rib removed only to enhance operative exposure;

(B) Therapeutic radioactive sources, the removal of which shall be guided by radiation safety monitoring requirements;

(C) Traumatically injured members that have been amputated and for which examination for either medical or legal reasons is not considered necessary;

(D) Specimens known to rarely, if ever, show pathological change, and the removal of which is highly visible postoperatively, including but not limited to the foreskin from circumcision of a newborn infant;

(E) Placentas that are grossly normal and have been removed in the course of operative and nonoperative obstetrics;

(F) Teeth, provided that the number, including fragments, is recorded in the medical record.

(n) Summary including final diagnosis;

(o) Date of discharge and discharge note;

(p) Autopsy report if applicable;

(q) Informed consent forms that document:

(A) The name of the ASC where the procedure or treatment was undertaken;

(B) The specific procedure or treatment for which consent was given;

(C) The name of the health care practitioner performing the procedure or administering the treatment;

(D) That the procedure or treatment, including the anticipated benefits, material risks, and alternatives was explained to the patient or the patient's representative or why it would have been materially detrimental to the patient to do so, giving due consideration to the appropriate standards of practice of reasonable health care practitioners in the same or a similar community under the same or similar circumstances;

(E) The manner in which care will be provided in the event that complications occur that require health services beyond what the ASC has the capability to provide. If the ASC has entered into agreements with more than one hospital, the patient must be provided with the most likely possible option, but that the transfer hospital may be dependent on the type of problem encountered.

(F) The signature of the patient or the patient's legal representative; and

(G) The date and time the informed consent was signed by the patient or the patient's legal representative;

(r) Documentation of the disclosures required in ORS 441.098; and

(s) Such signed documents as may be required by law.

(3) The completion of the medical record shall be the responsibility of the attending physician:

(a) Medical records shall be completed by the physician, dentist, podiatrist or other individual authorized within the scope of his or her professional license within four weeks following the patient's discharge;

(b) If a patient is transferred to another health care facility, transfer information shall accompany the patient. Transfer information shall include but not be limited to facility from which transferred; name of physician to assume care; date and time of discharge; current medical findings; current nursing assessment; current history and physical; diagnosis; orders from a physician for immediate care of the patient; operative report, if applicable; TB test, if applicable; other information germane to patient's condition. If discharge summary is not available at time of transfer, it shall be transmitted as soon as available.

(4) Diagnoses and operations shall be expressed in standard terminology.

(5) The medical records shall be filed in a manner which renders them easily retrievable. Medical records shall be protected against unauthorized access, fire, water and theft.

(6) Medical records are the property of the ASC. The medical record, either in original, electronic or microfilm form, shall not be removed from the institution except where necessary for a judicial or administrative proceeding. Authorized personnel of the Authority shall be permitted to review medical records. When an ASC 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.

(7) 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, microfilm, electronic or other media.

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

(9) If any ASC 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 (7) of this rule.

(10) 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.

(11) A current written policy on the release of medical record information including patient access to his or her medical record shall be maintained in the facility.

(12) 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 § 333-076-0165

HD 3-1990, f. 1-8-90, cert. ef. 1-15-90; PH 26-2010, f. 12-14-10, cert. ef. 12-15-10; PH 28-2016, f. & cert. ef. 10/6/2016; PH 1-2019, amend filed 01/07/2019, effective 1/7/2019

Statutory/Other Authority: ORS 441.025

Statutes/Other Implemented: ORS 441.025