OAR 333-077-0130: Medical Records

(1) A medical record shall be maintained for each client and newborn admitted for care. (2) Medical records must be completely and accurately documented, readily available, and systematically organized to facilitate the compilation and retrieval of information. Each client and newborn medical record must contain sufficient information to clearly identify the client. (3) A legible, reproducible medical record shall include at least the following (if applicable): (a) For the client: (A) Race, ethnicity, preferred spoken and written language, disability status, sexual orientation, and gender identity that meets the requirements of ORS 413.164 and OAR chapter 950, division 30; (B) Initial prenatal physical exam; (C) Laboratory tests and results; (D) Regular periodic prenatal and intrapartum examinations and assessments of risk status in accordance with OAR 333-077-0100 and OAR 333-077-0125; (E) A signed disclosure in accordance with OAR 333-077-0100; (F) Client history, physical exam and risk assessment on admission to the birthing center in labor (including assessment of fetus); (G) Regular periodic assessment (including assessment of the fetus) during labor and delivery in accordance with OAR 333-077-0100; (H) Labor summary; (I) The emergency transport plan (including the emergency transport plan for the newborn client); (J) Postpartum evaluation; (K) Discharge summary; (L) Documentation of assessments, consultation, referral, or transfer; (M) Documentation of disclosures pursuant to ORS 441.098; (N) Signed documents as may be required by law; and (b) For the newborn or stillborn delivery: (A) Date and hour of birth; (B) Birth weight; (C) Length of infant; (D) Period of gestation; (E) Sex assigned at birth; (F) Initial physical assessment and condition on delivery, including Apgar scores and vital signs; (G) Client's name; (H) Record of ophthalmic prophylaxis and Vitamin K administration or refusal of same; (I) Record of newborn hearing screening and cytomegalovirus screening, or record of referral to screening if screening is not provided by the birthing center; (J) Record of newborn metabolic screening or record of referral to screening if not provided by the birthing center; (K) Progress notes including: (i) Temperature, weight and feeding data; (ii) Stool output; (iii) Urinary output; (iv) Condition of eyes and umbilical cord; (v) Condition and color of skin; and (vi) Motor behavior; and (L) Discharge summary. (4) All entries in a client’s labor record must be promptly dated, timed, and authenticated: (a) Entries made 48 hours after the care has been provided must be identified as an addendum or an amended entry and must include the date and time of entry and the clinical providers initials. (b) Verification of an entry requires use of a unique identifier, for example, signature, code, or other means, that allows identification of the individual responsible for the entry. (c) A single signature or authentication of the responsible clinical provider or other individual authorized within the scope of their professional license on the medical record does not suffice to cover the entire content of the record. (5) The completion of the medical record is the responsibility of the attending clinical provider. (6)(a) The birthing center will ensure that the prenatal and intrapartal records are available at the time of admission and, in the event of transfer, the birthing center must ensure the following information accompanies the client or newborn client to the care of another clinician or hospital-based care: medical history, prenatal flow sheet, diagnostic studies, laboratory findings, and client and newborn care notes through time of transfer. (b) In cases of emergency, at the time of transfer, the birthing center must provide the information specified in subsection (6)(a) of this rule to the hospital-based care or another clinician, including notes for care provided during the emergency. If notes are not available, an oral summary of care during the emergency must be made available to the hospital-based care or responding EMS provider(s). (7) Medical records will be stored in such a way as to comply with state and federal privacy laws and minimize the chance of their destruction by fire or other source of loss or damage and to ensure prevention of access by unauthorized persons. (8) Medical records are the property of the birthing center, and will be kept confidential unless released by the permission of the client. The medical record, either in original or electronic form, shall not be removed from the birthing center except where necessary for a judicial or administrative proceeding. Authorized personnel of the Oregon Health Authority (Authority) shall be permitted to review medical records. If a birthing center uses off-site storage for medical records, arrangements must be made for prompt delivery of these records to the birthing center when needed for client care or other activities. (9) All clinical records must be kept for a period of at least seven years after the date of discharge for the birthing client and 21 years after the date of last discharge for the newborn client. Original medical records may be retained on paper, electronic, or other media. (10) If a birthing center changes ownership, all medical records in original, electronic, or other form must remain in the birthing center or off-site storage, and it must be the responsibility of the new owner to protect and maintain these records. (11) If a birthing center is permanently closed, its medical records may be delivered and turned over to any other health care facility in the vicinity willing to accept and retain the same as provided in section (9) of this rule. A birthing center which permanently closes shall follow the procedures for notifying the Authority and public notice requirements regarding disposal of medical records under OAR 333-077-0045. (12) A current written policy on the release of medical record information including client access to the medical record shall be maintained in the facility. (13) As part of its quality assessment and performance improvement program, a birthing center shall measure and evaluate its medical record documentation of care including timeliness of documentation. The following factors shall be considered during an evaluation: (a) Confidentiality of the record; (b) Records are easily retrievable; (c) Quality, legibility and accuracy of the information in the record; (d) Documentation of all requirements specified in these rules; (e) All entries are dated and timed; and (f) The timeliness of the entry. (14) A birthing center shall implement performance improvement activities based on its medical record evaluation. (15) A birthing center is encouraged to consult with a qualified clinical record practitioner to conduct its review. (16) As used in this rule, “qualified clinical record practitioner” means a Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT).