OAR 850-010-0310: Duty to Create, Maintain and Retain Medical Records

(1) Failure to keep complete, accurate, and minimally competent medical and billing records on all patients may result in discipline. (2) Licensee Duty to Maintain Clear, Legible, Complete, Accurate, and Minimally Competent Medical Records. Medical records shall contain the following: (a) Clear, legible, complete, and accurate information as to allow any other physician or treatment provider 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) Completed initial intake form in each patient’s medical record or chart. New patient information must contain date of visit, current legal name, date of birth, gender identification, contact information, presenting problem (i.e. reason for doctor visit), health history, allergies and medications currently taking; (c) Each page shall include patient name, date of birth, date of service, and licensee of record. Entries made by persons other than the licensee must be signed by the person making the entry and then co-signed by the licensee; (d) Description of the chief complaint or primary reason the patient sought treatment from the licensee; (e) Documentation of any reported changes in patient health history which affects the chief complaint or the general history of the health of the patient; (f) An accurate record of the diagnostic and therapeutic information that supports patient care, including but not limited to: (A) Clinically indicated vitals at the time of examination. If examination is via telemedicine, vitals may be reported by the patient, as clinically indicated. (B) Examinations and the results of those examinations; (C) Diagnoses; (D) All pertinent information to support patient care; treatment plan, patient response to treatment, and any subsequent changes to the treatment plan, and the clinical reasoning for those changes; (E) All medications prescribed by licensee, including over the counter medications, supplements, as well as dose and duration of medication; (F) Any specific concerns of the licensee; including lack of adherence with the treatment plan; (G) Documentation of informing patient of risk and permission to treat, as clinically indicated. (H) Other clinically relevant correspondence, including, but not limited to: text, telephonic, electronic or other patient communications, referrals to other practitioners, and expert reports. (3) Licensee Duty to Maintain and Retain Patient Medical Records. (a) If the treating naturopathic physician is an employee or associate, the duty to maintain entire records shall be with the business entity or licensed physician that employs or contracts with the treating naturopathic physician; (b) Naturopathic 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 six years from the date authored; (c) The responsibility for maintaining entire patient records may be transferred to another naturopathic business entity or to another naturopathic physician as part of a business ownership transfer transaction; (d) Except as provided for in paragraph (3)(a) of this rule, a naturopathic physician who is an independent contractor or who has an ownership interest in a naturopathic practice shall provide notice when leaving, selling, or retiring from the naturopathic office where the naturopathic physician has provided treatment and services; (e) Notification shall be sent to all patients who received services from the naturopathic physician during the two years immediately preceding the naturopathic physician’s last date for seeing patients. This notification shall be sent no later than thirty days prior to the last date the naturopathic physician will see patients. The notice shall include all of the following: (A) A statement that the naturopathic physician will no longer be providing treatment or services at the practice; (B) The date on which the naturopathic physician will cease to provide treatment and services; and (C) Contact information that enables the patient to obtain the patient’s records; (D) The notice shall be sent in one of the following ways: (i) 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 (ii) A secure electronic message. (E) In the event of an emergency or other unanticipated incident where a naturopathic physician is unable to provide a thirty day notice as required by paragraph (2)(f) of this rule, the naturopathic physician shall provide such notice within thirty days after it is determined that the physician will not be returning to practice. (F) A naturopathic 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. (4) A patient's entire health care record shall be kept by the naturopathic physician a minimum of six years from the date of last treatment. However, if a patient is a minor, the records must be maintained at least six years from the time they turn 18 years of age. (5) Disposal of all 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.