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Medical Records Collection, Retention, and Access in Oregon

        Oregon has a variety of laws governing the collection, maintenance of and access to patient medical records.  With respect to a patient’s access to their medical records, Oregon’s policy is to provide individuals the right to access and review their own protected health information.1

        With respect to maintenance of medical records, all health care facilities must maintain a record for each patient, including admitting data, a medical history and final diagnosis; such records must be retained for ten years from the date of discharge.2  Hospitals must maintain medical records in accordance with these standards, and comply with additional requirements for surgical patients, obstetrical patients and newborns.3

        The law also delineates specific medical record maintenance and retention requirements for certain health care facilities. Birthing centers must maintain health and clinical records for 21 years from date of last discharge.4

In-home care agencies,5 renal dialysis facilities,6 community mental health and disability service providers,7 licensed direct entry midwives,8 and non-inpatient mental health service providers9 must maintain client records for seven years after the date of last service to the client.  Nursing facilities must maintain a clinical record for all residents for five years from the date of discharge.10  Adult foster homes must maintain a record for all admitted residents for three years after discharge,11 and pharmacists must retain a record sufficient to perform a drug utilization review for three years.12

 

Footnotes

  • 1. Or. Rev. Stat. §192.518
  • 2. Or. Admin. R. 333-071-0060
  • 3. Or. Admin. R.  333-505-0050
  • 4. Or. Admin. R. 333-076-0690
  • 5. Or. Admin. R. 333-536-0085
  • 6. Or. Admin. R. 333-700-0090
  • 7. Or. Admin. R. 309-014-0035
  • 8. Or. Admin. R. 332-025-0070
  • 9. Or. Admin. R. 309-039-0540
  • 10. Or. Admin. R.  411-086-0300
  • 11. Or. Admin. R. 309-040-0390
  • 12. Or. Admin. R. 855-019-0220

 

Medical Records Collection, Retention, and Access in Oregon

Subtopic Statute/Regulation Description
Content of medical record 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: Admitting...
Or. Admin. R. 410-120-1360 - Requirements for Financial, Clinical and Other Records Medicaid participating providers must maintain financial and clinical records.  The records must be well documented and be complete before...
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...
Or. Admin. R. 309-032-0870 - Standards for Approval of Regional Acute Care Psychiatric Service In order to be granted approval for operation, regional acute care psychiatric services must comply with the following requirements: Maintain...
Or. Admin. R. 309-040-0390 - Standards and Practices for Care and Services Adult Foster Homes must comply with a number of standards for care and services, including the following: Maintain a copy of medication,...
Or. Admin. R. 332-025-0110 - Records of Care Practice Standards Licensed direct entry midwives must maintain complete and accurate written records of each mother and baby, including a description of the care...
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...
Or. Admin. R. 333-076-0165 - Medical Records All ambulatory surgical centers must maintain a medical record for each patient admitted for care.  Medical records are the property of the...
Or. Admin. R. 333-076-0690 - Health and Medical Records Birthing Centers must maintain health and clinical records for each client and must store such records to prevent access by unauthorized persons....
Or. Admin. R. 333-536-0085 - Client Records Every in-home care agency must maintain a record for each client served by the agency.  Clients’ records are the property of the agency,...
Or. Admin. R. 333-700-0090 - Medical Records Each renal dialysis facility must maintain complete medical records on all patients; each record must contain sufficient information to identify the...
Or. Admin. R. 847-017-0020 - Patient Medical Records A comprehensive medical record must be maintained for each patient who is evaluated or treated in an office-based surgery setting.  The record...
Required maintenance of medical records 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...
Or. Admin. R. 309-014-0035 - General Standards for Delivery of Community Mental Health and Developmental Disability Service Elements All community mental health and developmental disability contractors providing services under a contract with the Oregon Health Authority’s...
Or. Admin. R. 309-032-0870 - Standards for Approval of Regional Acute Care Psychiatric Service In order to be granted approval for operation, regional acute care psychiatric services must comply with the following requirements: Maintain...
Or. Admin. R. 309-039-0540 - General Standards Each provider of non-inpatient mental health treatment services are required to meet a number of standards, including: Have written policies and...
Or. Admin. R. 309-040-0390 - Standards and Practices for Care and Services Adult Foster Homes must comply with a number of standards for care and services, including the following: Maintain a copy of medication,...
Or. Admin. R. 332-025-0110 - Records of Care Practice Standards Licensed direct entry midwives must maintain complete and accurate written records of each mother and baby, including a description of the care...
Or. Admin. R. 333-004-0060 - Standards of Care for Contraceptive Management Services Providers participating in the Family Planning Expansion Program must agree to provide contraceptive management services according to the following...
Or. Admin. R. 333-004-0120 - Requirements for Financial, Clinical and Other Records The Office of Family Health is responsible for analyzing and monitoring the operation of the Family Planning Expansion Program and for auditing and...
Or. Admin. R. 333-018-0120 - HAI Reporting for Long Term Care Facilities Long Term Care Facilities must report outcome measures using the Center for Medicare and Medicaid Services’ minimum data set nursing home...
Or. Admin. R. 333-018-0125 - HAI Reporting for Other Health Care Facilities Beginning on January 1, 2013, dialysis facilities must begin collecting data for the Health Care Acquired Infection Reporting Program.
Or. Admin. R. 333-027-0150 - Clinical Records Every home health agency must maintain a clinical record for each patient that must include the patient’s identifying information, clinical...
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...
Or. Admin. R. 333-076-0165 - Medical Records All ambulatory surgical centers must maintain a medical record for each patient admitted for care.  Medical records are the property of the...
Or. Admin. R. 333-076-0690 - Health and Medical Records Birthing Centers must maintain health and clinical records for each client and must store such records to prevent access by unauthorized persons....
Or. Admin. R. 333-536-0060 - Clients’ Rights Clients of in-home care agencies have a number of a rights, including the following: To be given the informed choice and opportunity to select or...
Or. Admin. R. 333-536-0085 - Client Records Every in-home care agency must maintain a record for each client served by the agency.  Clients’ records are the property of the agency,...
Or. Admin. R. 333-700-0090 - Medical Records Each renal dialysis facility must maintain complete medical records on all patients; each record must contain sufficient information to identify the...
Or. Admin. R. 410-120-1855 - Client’s Rights and Responsibilities Client’s Rights and Responsibilities Division of Medical Assistance Program clients have several rights, including: Be actively involved in...
Or. Admin. R. 410-125-1040 - Accounting and Record Keeping All Medicare records must be kept for three years after the Medicare audit has been finalized.  Hospitals are required to make their financial...
Or. Admin. R. 410-141-0180 - Oregon Health Plan Prepaid Health Plan Record Keeping Prepaid Health Plans (PHPs) and participating providers must have written policies and procedures to ensure that individually identifiable health...
Or. Admin. R. 410-141-0720 - Oregon Health Plan Primary Care Manager Medical Record Keeping A Primary Care Manager (PCM) is a health care provider that agrees to provide primary care management services to an Oregon Health Plan client...
Or. Admin. R. 411-085-0310 - Residents’ Rights: Generally All residents in a nursing facility have the following rights: To be fully informed of one’s health and medical status; To be fully...
Or. Admin. R. 847-017-0020 - Patient Medical Records A comprehensive medical record must be maintained for each patient who is evaluated or treated in an office-based surgery setting.  The record...
Or. Admin. R. 855-019-0220 - Drug Utilization Review (DUR) Pharmacists must maintain a record for each patient that contains information necessary for the pharmacist to perform a drug utilization review....
Or. Rev. Stat. § 410.480 - Required record keeping Each authorized agency and service provider for Oregon Project Independence shall maintain books, records, documents and accounting procedures which...
Or. Rev. Stat. § 431.966 - Disclosure of information Patient data submitted as part of the prescription monitoring program is considered protected health information and is not subject to disclosure as...
Or. Rev. Stat. § 441.605 - Legislative declaration of rights intended for residents Residents of nursing homes are guaranteed several rights, including the following: To be fully informed by a physician of the medical condition...
Right to access to medical records (Access by representative or other person authorized by the patient through informed consent; copying fees, or other requirements (e.g., requirement to give patient access in electronic format)) Or. Admin. R. 114-005-0030 - Access to Records The Long Term Care Ombudsman and his designees may access any long term care resident’s records with the written authorization of the resident...
Or. Admin. R. 309-012-0070 - Policy A patient utilizing Mental Health Services via the Addictions and Mental Health Division of the Oregon Health Authority may review his or her own...
Or. Admin. R. 333-004-0120 - Requirements for Financial, Clinical and Other Records The Office of Family Health is responsible for analyzing and monitoring the operation of the Family Planning Expansion Program and for auditing and...
Or. Admin. R. 333-010-0060 - Special Studies The Oregon Health Authority’s Public Health Division may conduct special studies of cancer mortality and morbidity, and is authorized to obtain...
Or. Admin. R. 333-018-0125 - HAI Reporting for Other Health Care Facilities Beginning on January 1, 2013, dialysis facilities must begin collecting data for the Health Care Acquired Infection Reporting Program.
Or. Admin. R. 333-027-0080 - Patients' Rights Each patient of a home health agency has a number of rights, including the following: To be informed, in advance, about the care to be furnished...
Or. Admin. R. 333-049-0060 - Access to Immunization Records Clients and parents or guardians of clients under age 18 may request a copy of their or their child’s immunization record to the immunization...
Or. Admin. R. 407-014-0030 - Client Privacy Rights Client, defined as individuals requesting services from the Department of Human Services, including recipients of public assistance, may access,...
Or. Admin. R. 411-045-0100 - Confidentiality and Reporting Each Program of All-Inclusive Care for the Elderly (PACE) must have written policies and procedures to assure that participants’ clinical...
Or. Admin. R. 847-012-0000 - Patient’s Access to Medical Records A patient or his or her personal representative has the right to request access to all or part of the patient's protected health information in the...
Or. Rev. Stat. § 192.563 - Health care provider and state health plan charges A health care provider or state health plan that receives an authorization for disclosure of protected health information may charge a fee associated...
Or. Rev. Stat. § 441.117 - Right of entry into facilities and access to records The Long Term Care Ombudsman will have access to any long term care facility resident’s records, and to necessary records of any public agency...
Retention periods Or. Admin. R. 309-040-0390 - Standards and Practices for Care and Services Adult Foster Homes must comply with a number of standards for care and services, including the following: Maintain a copy of medication,...
Or. Admin. R. 333-004-0120 - Requirements for Financial, Clinical and Other Records The Office of Family Health is responsible for analyzing and monitoring the operation of the Family Planning Expansion Program and for auditing and...
Or. Admin. R. 333-027-0150 - Clinical Records Every home health agency must maintain a clinical record for each patient that must include the patient’s identifying information, clinical...
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...
Or. Admin. R. 333-076-0165 - Medical Records All ambulatory surgical centers must maintain a medical record for each patient admitted for care.  Medical records are the property of the...
Or. Admin. R. 333-076-0690 - Health and Medical Records Birthing Centers must maintain health and clinical records for each client and must store such records to prevent access by unauthorized persons....
Or. Admin. R. 333-536-0085 - Client Records Every in-home care agency must maintain a record for each client served by the agency.  Clients’ records are the property of the agency,...
Or. Admin. R. 333-700-0090 - Medical Records Each renal dialysis facility must maintain complete medical records on all patients; each record must contain sufficient information to identify the...
Or. Admin. R. 410-141-0720 - Oregon Health Plan Primary Care Manager Medical Record Keeping A Primary Care Manager (PCM) is a health care provider that agrees to provide primary care management services to an Oregon Health Plan client...
Or. Admin. R. 855-019-0220 - Drug Utilization Review (DUR) Pharmacists must maintain a record for each patient that contains information necessary for the pharmacist to perform a drug utilization review....
Destruction, storage and filing of medical records (Cross reference with Security of Health Information) Or. Admin. R. 333-011-0315 - Disposition of Reports of Induced Termination of Pregnancy Reports of induced termination of pregnancy are statistical reports only and may not be incorporated into the official records of the vital...
Or. Admin. R. 333-027-0150 - Clinical Records Every home health agency must maintain a clinical record for each patient that must include the patient’s identifying information, clinical...
Or. Admin. R. 333-076-0690 - Health and Medical Records Birthing Centers must maintain health and clinical records for each client and must store such records to prevent access by unauthorized persons....
Or. Admin. R. 333-536-0085 - Client Records Every in-home care agency must maintain a record for each client served by the agency.  Clients’ records are the property of the agency,...
Or. Admin. R. 333-700-0090 - Medical Records Each renal dialysis facility must maintain complete medical records on all patients; each record must contain sufficient information to identify the...
Medical Records Collection, Retention, and Access Or. Rev. Stat. § 438.430 - Examination, specimens A clinical laboratory must report the result of any test, examination or analysis of a submitted specimen submitted to the patient, to the provider...
Or. Rev. Stat. §192.553 - Policy for protected health information It is Oregon's policy that an individual has the right to have his or her protected health information safeguarded from unlawful use or disclosure,...
Or. Rev. Stat. §192.553 - Policy for protected health information Oregon’s policy is that individual health information must be protected from unlawful use or disclosure.  It also provides that an...
Or. Rev. Stat. §432.350 - Vital records exempt from public disclosure It is unlawful for any person to allow an unauthorized person to inspect, disclose, or copy information from vital records or reports in the...