OAR 333-510-0010: Patient Admission and Treatment Orders

(1) No patient, including patients admitted for observation status, shall be admitted to a hospital except on the order of an individual who has admitting privileges. The admitting physician, physician associate or nurse practitioner shall provide sufficient information at the time of admission to establish that care can be provided to meet the needs of the patient. Admission medical information shall include a statement concerning the admitting diagnosis and general condition of the patient. Other pertinent medical information, orders for medication, diet, and treatments shall also be provided, as well as a medical history and physical. (2) Within 24 hours of a patient’s admission, a hospital shall ensure that: (a) The patient’s medical history is taken and a physical examination performed, unless: (A) A medical history and physical examination has been completed within 30 days prior to admission, as provided in the medical staff rules and regulations; or (B) The patient is readmitted within a month's time for the same or related condition, as long as an interval note is completed. (b) The patient is given a provisional diagnosis. (3) Even if a medical history or physical examination at the time of admission is not required under section (2) of this rule, a hospital shall ensure that any changes crucial to patient care are noted in an admission note. (4) Visits from licensed health care providers shall be according to patient's needs. Initial and ongoing assessments shall be performed for each patient and the results and observations recorded in the medical record. (5) A Doctor of Medicine (MD), Doctor of Osteopathy (DO), Physician Associate (PA) or nurse practitioner with admitting privileges shall be responsible, as permitted by the individual's scope of practice for the care of any medical problem that may be present on admission or that may arise during an inpatient stay. (6) No medication or treatment shall be given except on the order of a licensed healthcare professional authorized to give such orders within the State of Oregon.