Skip to Content

Or. Admin. R. 411-086-0300 - Clinical Records

Link to the law
This will open in a new window

Nursing facilities must maintain a clinical record for each resident.  A clinical records coordinator must be designated to ensure compliance with the rules.  There must be employees, space, and equipment for clinical records, as well as a filing system for the records.  Clinical records must include the following information:

  1. Identification information of the resident, such as name, address, date of birth, and sex, as well as an admitting diagnosis;
  2. Medical history and physical exam;
  3. Clinical reports;
  4. Physician’s orders and notes;
  5. Clinical observations of the resident;
  6. Record of medication administration;
  7. Record of treatments;
  8. Discharge summary;

All clinical records must be retained for at least 5 years from the date of discharge of the resident.  Clinical records are the property of the nursing facility.

Current as of June 2015