Or. Admin. R. 333-076-0690

Current through Register Vol. 63, No. 9, September 1, 2024

Section 333-076-0690 - Health and Medical Records

Health and Clinical Records must be developed according to procedures outlined in the Policy and Procedures Manual as a legal record and an instrument for the continuity of care and must include:

(1) Contents -- The records of each client must contain:

(a) Demographic data, initial prenatal physical examination, laboratory tests and evaluation of risk status;

(b) Continuous periodic prenatal examination and evaluation of risk status;

(c) A signed informed consent (refer also to OAR 333-076-0670(12));

(d) History, physical examination and risk assessment on admission to the Center in labor (including assessment of mother and fetus);

(e) Continuous assessment of the mother and fetus during labor and delivery;

(f) Labor summary;

(g) The emergency transport plan for the client;

(h) Physical assessment of newborn, including Apgar scores and vital signs;

(i) Post partum evaluation of the mother;

(j) Discharge summary for mother and newborn;

(k) Documentation of consultation, referral, and/or transfer;

(l) Signed documents as may be required by law; and

(m) Records of newborn and stillborn infants must include, in addition to the requirement for medical records, the following information:

(A) Date and hour of birth, birth weight and length of infant, period of gestation, sex, and condition of infant on delivery;

(B) Mother's name;

(C) Record of ophthalmic prophylaxis and Vitamin K administration or refusal of same; and

(D) Progress notes including:

(i) Temperature, weight and feeding data;

(ii) Number, consistency and color of stools;

(iii) Urinary output;

(iv) Condition of eyes and umbilical cord;

(v) Condition and color of skin; and

(vi) Motor behavior.

(2) All entries in a client's labor record must be dated, timed, and authenticated. Verification of an entry requires use of a unique identifier, i.e., signature, code, thumbprint, voice print or other means, that allows identification of the individual responsible for the entry.

(3) A single signature or authentication of the responsible practitioner on the clinical record does not suffice to cover the entire content of the record.

(4) The completion of the clinical record must be the responsibility of the attending practitioner.

(5) The Center will ensure that the prenatal and intrapartal records are available at the time of admission and in the event of transfer to the care of another clinician or health care facility.

(6) Storage -- The records will be stored in such a way as to minimize the chance of their destruction by fire or other source of loss or damage and to ensure prevention of access by unauthorized persons.

(7) Records are the property of the Center, and will be kept confidential unless released by the permission of the client. An exception is that they may be reviewed by representatives of the Division, and will be provided in copy form to such representatives on request.

(8) All clinical records must be kept for a period of at least twenty-one years after the date of last discharge. Original clinical records may be retained on paper, microfilm, electronic or other media.

(9) If a Center changes ownership all clinical records in original, electronic, or microfilm form must remain in the Center, and it must be the responsibility of the new owner to protect and maintain these records.

(10) If a Birthing Center must be closed, its clinical records may be delivered and turned over to any other health care facility in the vicinity willing to accept and maintain the same as provided in section (8) of this rule.

(11) If a qualified clinical record practitioner, RHIA (Registered Health Information Administrator) or RHIT (Registered Health Information Technician) is not the Director of the Clinical Records Department, the Division may require the Center to obtain periodic and at least annual consultation from a qualified clinical records consultant, RHIA/RHIT. The visits of the clinical records consultant must be of sufficient duration and frequency to review clinical record systems and assure quality records of the clients. Contract for such services must be available to the Division.

Or. Admin. R. 333-076-0690

HD 26-1985, f. & ef. 10-28-85; HD 2-1990, f. 1-8-90, cert. ef. 1-15-90, Renumbered from 333-076-0425; PH 15-2006, f. & cert. ef. 6-27-06

Stat. Auth.: ORS 441.025 & 442.015

Stats. Implemented: ORS 441.025 & 442.015