OAR 415-020-0017: Patient Records

(1) Patient Recordkeeping: Each program shall: (a) Accurately record all information about patients as required by these rules in the permanent patient record; (b) Maintain each patient record to assure identification, accessibility, uniform organization, and completeness of all components required by these rules and in a manner to protect against damage or separation from the permanent patient or program record; (c) Keep all documentation current .unless specified otherwise, within seven days of delivering the service or obtaining the information; (d) Include the signature of the person providing the documentation and service; (e) Not falsify, alter, or destroy any patient information required by these rules to be maintained in a patient record or program records; (f) Document all procedures in these rules requiring patient consent and the provision of information to the patient on forms describing what the patient has been asked to consent to or been informed of, and signed and dated by the patient. If the program does not obtain documentation of consent or provision of required information, the reasons must be specified in the patient record and signed by the person responsible for providing the service to the patient; (g) Require that errors in the permanent record be corrected by lining out the incorrect data with a single line in ink, adding the correct information, and dating and initialing the correction. Errors may not be corrected by removal or obliteration through the use of correction fluid or tape so they cannot be read; and (h) Permit inspection of patient records upon request by the Division to determine compliance with these rules. (2) Patient and Fiscal Record Retention: Patient records shall be kept for a minimum of seven years. If a program is taken over or acquired by another program, the original program is responsible for assuring compliance with the requirements of 42 CFR § 2.19(a)(1) or (b), whichever is applicable. If a program discontinues operations, the program is responsible for: (a) Transferring fiscal records required to be maintained under section (1) of this rule to the Division if it is a direct contract or to the community mental health program or managed care plan administering the contract, whichever is applicable; and (b) Destroying patient records or, with patient consent, transferring patient records to another program.