Or. Admin. R. 333-071-0060 - Medical Records

All health care facilities must maintain medical records for each patient that is admitted.  The medical record must include the following information:

1. Admitting data
2. Chief complaint
3. Family and medical history
4. Lab reports
5. X-ray reports
6. Assessment and interventions
7. Final diagnosis
8. Date of discharge

It is the responsibility of the attending physician to complete a patient’s medical record before he or she is discharged or transferred.  Medical records must be protected from unauthorized access and be easy to retrieve.  Medical records are the property of the health care facility.  Medical records may be moved to an off-site storage facility, but precautions must be taken to protect patient confidentiality. 

All medical records must be retained for at least 10 years from the date of discharge.  The records may be kept in paper, microfilm or electronic formats.  All other clinical records such as x-rays or electrocardiograms must be retained for at least 7 years after the patient’s discharge.  The facility must maintain a written policy regarding patient access to his or her own medical records.