OAR 331-840-0060: Client Records

(1) Certificate holders must maintain documentation for each client relevant to health history, clinical examinations and treatment, and financial data. (2) Records must include: (a) Client’s name, address, telephone number and dates of service; (b) Health history related to sexual-abuse-specific evaluation or treatment plan(s), including referral to other mental health-care provider or physician. (c) Description of services -- chart notes -- including any complications. Chart notes must include the recorder’s initials, certification number and professional title if multiple practitioners provide service to the client. (3) Certificate holder’s name, license number, professional title or abbreviation, and signature or initials somewhere on the documentation as a means of identifying the person who is providing service to the client. This information may be affixed to the record(s) in the form of a professional stamp or handwritten entry. (4) Client records and documentation must be retained for at least 7 years after the certificate holder stops working with the client.