OAR 811-015-0005: Records

(1) Failure to keep complete, accurate, and minimally competent records on all patients shall be considered unprofessional conduct. (a) Each patient shall have exclusive records which shall be clear, legible, complete, and accurate as to allow any other chiropractic physician to understand the nature of that patient's case and to be able to follow up with the care of that patient, if necessary. (b) Every page of chart notes will identify the patient by name and one other unique identifier (date of birth, medical record number, etc.), and the clinic of origin by name and address. Each entry will be identified by day, month, year, provider of service, and author of the record. (c) Clear, legible, complete, accurate, and minimally competent records shall contain the following: (A) A description of the chief complaint or primary reason the patient sought treatment from the licensee. (B) Documentation of any significant event that affects the chief complaint of the patient or the general history of the health of the patient. (C) An accurate record of the diagnostic and therapeutic procedures that the licensee has employed in providing chiropractic services to the patient, including, but not limited to: (i) Height, weight, blood pressure, and pulse at initial examination. If initial examination is via telemedicine, record patient's height and weight by patient's report. Record blood pressure and pulse if patient is able to obtain remotely. Height, weight, blood pressure and pulse is recorded on subsequent visits, as clinically indicated; (ii) Examinations and the results of those examinations; (iii) Diagnoses; (iv) Treatment plan, any subsequent changes to the treatment plan, and the clinical reasoning for those changes; (v) Dates on which the licensee provided clinical services to the patient, as well as the services performed, and clinical indications for those services; (vi) Areas of the patient’s body where the licensee has provided care; (vii) Patient’s response to treatment; (viii) Therapeutic procedures must be clearly described including information such as providers involved, timing, setting, and tools used, as appropriate. (D) Document written informed consent has been obtained in the chart. Regarding informed consent and PARQ (Procedures, Alternatives, Risks, and Questions) requirements, refer to OAR 811-035-0005 (2)(a) and (b). (E) Other clinically relevant correspondence, including, but not limited to: telephonic or other patient communications, referrals to other practitioners, and expert reports. (d) A chiropractic physician shall maintain billing records for services performed for which payment is received from or billed to the patient, an insurance company, or another person or entity who has assumed the financial responsibility for the payment of services performed to the patient. Such records will be maintained for the same amount of time as other patient records. At a minimum, a billing record will include the date of the patient encounter or financial entry, a notation of the services performed either by description or code, common codes such as the AMA Current Procedural Terminology (CPT) codes may be used without additional explanation or legend, and the fee charged for the services billed. If third party payors are billed, the billing instrument (CMS 1500 form or its successor) should be retrievable. Such information may be maintained on a handwritten or printed ledger, with the assistance of a computer or other device either by direct entry or with a particular program or application, or by an alternative method. To the extent billing records do not contain patient health care records not kept elsewhere, they are not considered part of the clinical record. (e) Such information as described in section (d) must be readily available upon request of the patient, an agent of the patient, an insurance carrier or entity responsible for the payment of the services, or by the Board or other entity with a legal right to review such information. (2) Practitioners with dual licenses shall indicate on each patient's records under which license the services were rendered. (3) A patient's entire health care and billing records shall be kept by the chiropractic physician a minimum of seven years from the date of last treatment. However, if a patient is a minor, the records must be maintained at least seven years from the time they turn 18 years of age. (a) If the treating chiropractic physician is an employee or associate, the duty to maintain entire records shall be with the chiropractic business entity or chiropractic physician that employs or contracts with the treating chiropractic physician. (b) Chiropractic physicians providing file reviews, second opinion consultations, or independent medical examinations (IME) shall be responsible for keeping an available copy of all authored reports for seven years from the date authored. (4) If a chiropractic physician releases original radiographic films to a patient or another party, upon the patient’s written request, they should create an expectation that the films will be returned, and a notation shall be made in the patient’s file or in an office log where the films are located (either permanently or temporarily). If a chiropractic physician has radiographic films stored outside their clinic, a notation shall be made in the patient’s file or in an office log where the films are located and the chiropractic physician must ensure those films are available for release, if requested by the patient. (5) The responsibility for maintaining entire patient records may be transferred to another chiropractic business entity or to another chiropractic physician as part of a business ownership transfer transaction. (6)(a) A chiropractic physician shall establish a plan for custodianship of these records in the event they are incapacitated, become deceased, are or will become unable to maintain these records pursuant to paragraph (6)(b). (b) In the event a chiropractic physician dies or becomes incapacitated and unable to practice, and there is no other chiropractic physician associated with the practice, the deceased, incapacitated, or unavailable chiropractic physician’s personal representative, guardian, administrator, conservator, next of kin, or other legal representative shall notify the Board in writing of the management arrangement for the custody and transfer of patient files and records. This individual shall ensure the security of, and access to, patient files and records by the patient or other authorized party, and must report plans or arrangements for permanent custody of patient files and records to the Board in writing within 180 days. Transfer of patient files and records must occur within one year of the death of the chiropractic physician. (7) Except as provided for in paragraph (7)(e) of this rule, a chiropractic physician who is an independent contractor or who has an ownership interest in a chiropractic practice shall provide notice when leaving, selling, or retiring from the chiropractic office where the chiropractic physician has provided chiropractic services. (a) Notification shall be sent to all patients who received services from the chiropractic physician during the two years immediately preceding the chiropractic physician’s last date for seeing patients. This notification shall be sent no later than thirty days prior to the last date the chiropractic physician will see patients. (b) The notice shall include all of the following: (A) A statement that the chiropractic physician will no longer be providing chiropractic services at the practice; (B) The date on which the chiropractic physician will cease to provide services; and (C) Contact information that enables the patient to obtain the patient’s records. (c) The notice shall be sent in one of the following ways: (A) A letter sent through the US Postal Service to the last known address of the patient with the date of the mailing of the letter documented, or (B) A secure electronic message. (d) In the event of an illness, unforeseen emergency, incarceration, or other unanticipated incident, a chiropractic physician is unable to provide a thirty day notice as required by paragraph (7)(a) of this rule, the chiropractic physician shall provide such notice within thirty days after it is determined that the physician will not be returning to practice. (e) Paragraph (7) of this rule does not apply to the chiropractic physician who is departing as an employee of another Oregon licensed chiropractic physician. It is the employer’s responsibility to maintain continuity of care, or to comply with this rule, if patient care will be terminated upon an employee’s leaving employment or retiring. (8) Disposal of records shall be completed by a process that results in permanent destruction of the records and shall be compliant with all state and federal law.