OAR 847-017-0020: Patient Medical Records

(1) A legible, complete, comprehensive and accurate medical record must be maintained for each patient evaluated or treated. The record must include: (a) Identity of the patient; (b) History and physical, diagnosis and plan; (c) Appropriate lab, x-ray or other diagnostic reports; (d) Documentation of the PARQ conference; (e) Disclosure of the licensee’s specialty board certification through the ABMS, the AOA-BOS, the ABPM, the ABFAS or the NCCPA or lack thereof; (f) Appropriate preanesthesia evaluation; (g) Narrative description of procedure; (h) Intraoperative and postoperative monitoring; (i) Pathology reports; (j) Documentation of the outcome and the follow-up plan; and (k) Provision for continuity of post-procedure care. (2) If the office-based surgery is a Level II or Level III surgical procedure, the patient record must include a separate anesthetic record that contains documentation of anesthetic provider, ASA Physical Status, procedure, and technique employed. This must include the type of anesthesia used, drugs (type and dose) and fluids administered during the procedure, patient weight, level of consciousness, estimated blood loss, duration of procedure, and any complication or unusual events related to the procedure or anesthesia. (3) The patient record must document if tissues and other specimens have been submitted for histopathologic diagnosis. (4) The licensee must ensure that the facility has specific and current protocols in place for patient confidentiality and security of all patient data and information.