Or. Admin. R. 333-505-0050 - Medical Records

Hospitals must maintain medical records for each patient that is admitted.  The record must include the following information:

1. Admitting identification data, including date of admission;
2. Main complaint;
3. Family and past medical history;
4. Admission, treatment and discharge orders;
5. Laboratory reports;
6. X-rays;
7. Informed consent forms;

All entries in a patient’s medical record must be dated and authenticated.  Certain records, such as a register of all patients and register of all deaths must be kept permanently by the hospital either in paper form or electronically. 

There are additional requirements for the medical record of a surgical patient, including pre-and post-operation information and anesthesia record.  For obstetrical patients, information regarding prenatal care, labor and delivery information, and any medical interventions given, are required to be included in the medical record.  Medical records for newborns must include time of birth, weight, mother’s name, physical examination results, and newborn screening tests. 

All medical records are the property of the hospital.  Hospitals must retain medical records for at least ten years from the date of discharge.  Records can be kept in paper, microfilm, or electronic format.  All other items that are not otherwise included in the patient’s medical record, such as x-rays or electrocardiograms must be retained for seven years from discharge.  The hospital must maintain a written policy on the release of medical information, including patient access to medical records.