Or. Admin. R. 411-086-0300 - Clinical Records

Nursing facilities must maintain a clinical record for each resident.  A clinical records coordinator must be designated to ensure compliance with the rules.  There must be employees, space, and equipment for clinical records, as well as a filing system for the records.  Clinical records must include the following information:

1. Identification information of the resident, such as name, address, date of birth, and sex, as well as an admitting diagnosis;
2. Medical history and physical exam;
3. Clinical reports;
4. Physician’s orders and notes;
5. Clinical observations of the resident;
6. Record of medication administration;
7. Record of treatments;
8. Discharge summary;

All clinical records must be retained for at least 5 years from the date of discharge of the resident.  Clinical records are the property of the nursing facility.