OAR 333-536-0085: Client Records

(1) A client record shall be maintained for every client served by an agency, unless the client receives only housekeeping or support services, and shall be maintained in the agency’s office. (2) A legible, reproducible client record which is easily accessible and readily available, shall include at least the following: (a) Identification data; (b) Referral; (c) Start-of-service date; (d) Disclosure documents and documentation required by these rules; (e) Clients' rights documentation required by these rules; (f) All client evaluation and assessment documentation; (g) Client service plan and updates; (h) Documentation of all services provided, including daily caregiver notes recording a summary of the tasks completed, observation of the client, and observed or reported concerns; (i) Service and financial agreement signed by a client or a client's representative before the initiation of services that specifies the services to be provided in accordance with the service plan, and the costs for those services; (j) End-of-services date; and (k) End-of-service summary, including the dates of service and the disposition of the client. (3) All entries and documents in the record must be recorded in ink, typescript, or computer-generated. (4) All entries in a client's record must be dated and signed, or otherwise authenticated by the person making the entry. For purposes of this rule, authenticated means verification by the author that an entry in the client record is genuine. Electronic authentication is acceptable as long as there is a process for reconstruction of the information and there are safeguards to prevent unauthorized access to the records. (5) A client record shall be maintained in a manner that renders it easily retrievable. (6) Reasonable precautions must be taken to protect a client’s record and information from unauthorized access, fire, water, and theft. (7) In an effort to coordinate services and care with other providers, including but not limited to, hospice, home health, and family members, as required in OAR 333-536-0055(1)(c), charting notes within a client’s home may be shared, as permitted by law. (8) Authorized employees of the Authority shall be permitted to review client records upon request. Photocopies of the records shall be made upon request. (9) All clients' records shall be kept for a period of at least seven years after the date of last end-of-service. (10) Clients' records are the property of the agency. (11) If an agency has a change of ownership, all clients' records shall remain in the agency, and it shall be the responsibility of the new owner to protect and maintain these records. (12) Before an agency terminates its business, the agency shall notify the Authority where the clients' records will be stored. (13) An agency shall comply with the additional documentation requirements specified in subsection (2)(h) of this rule no later than January 1, 2022.