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Medical Records Collection, Retention, and Access in Oregon

        Oregon has a variety of laws governing the collection, maintenance of and access to patient medical records.  With respect to a patient’s access to their medical records, Oregon’s policy is to provide individuals the right to access and review their own protected health information.1

        With respect to maintenance of medical records, all health care facilities must maintain a record for each patient, including admitting data, a medical history and final diagnosis; such records must be retained for ten years from the date of discharge.2  Hospitals must maintain medical records in accordance with these standards, and comply with additional requirements for surgical patients, obstetrical patients and newborns.3

        The law also delineates specific medical record maintenance and retention requirements for certain health care facilities. Birthing centers must maintain health and clinical records for 21 years from date of last discharge.4

In-home care agencies,5 renal dialysis facilities,6 community mental health and disability service providers,7 licensed direct entry midwives,8 and non-inpatient mental health service providers9 must maintain client records for seven years after the date of last service to the client.  Nursing facilities must maintain a clinical record for all residents for five years from the date of discharge.10  Adult foster homes must maintain a record for all admitted residents for three years after discharge,11 and pharmacists must retain a record sufficient to perform a drug utilization review for three years.12

 

Footnotes

  • 1. Or. Rev. Stat. §192.518
  • 2. Or. Admin. R. 333-071-0060
  • 3. Or. Admin. R.  333-505-0050
  • 4. Or. Admin. R. 333-076-0690
  • 5. Or. Admin. R. 333-536-0085
  • 6. Or. Admin. R. 333-700-0090
  • 7. Or. Admin. R. 309-014-0035
  • 8. Or. Admin. R. 332-025-0070
  • 9. Or. Admin. R. 309-039-0540
  • 10. Or. Admin. R.  411-086-0300
  • 11. Or. Admin. R. 309-040-0390
  • 12. Or. Admin. R. 855-019-0220

 

Medical Records Collection, Retention, and Access in Oregon

Subtopic Statute/Regulation Description
Medical Records Collection, Retention, and Access Access to Immunization Records - Or. Admin. R. 333-049-0060 Clients and parents or guardians of clients under age 18 may request a copy of their or their child’s immunization record to the immunization...
Accounting and Record Keeping - Or. Admin. R. 410-125-1040 All Medicare records must be kept for three years after the Medicare audit has been finalized.  Hospitals are required to make their financial...
Client Privacy Rights - Or. Admin. R. 407-014-0030 Client, defined as individuals requesting services from the Department of Human Services, including recipients of public assistance, may access,...
Client Records - Or. Admin. R. 333-536-0085 Every in-home care agency must maintain a record for each client served by the agency.  Clients’ records are the property of the agency,...
Clients’ Rights - Or. Admin. R. 333-536-0060 Clients of in-home care agencies have a number of a rights, including the following: To be given the informed choice and opportunity to select or...
Client’s Rights and Responsibilities - Or. Admin. R. 410-120-1855 Client’s Rights and Responsibilities Division of Medical Assistance Program clients have several rights, including: Be actively involved in...
Clinical Records - Or. Admin. R. 411-086-0300 Nursing facilities must maintain a clinical record for each resident.  A clinical records coordinator must be designated to ensure compliance...
Clinical Records - Or. Admin. R. 333-027-0150 Every home health agency must maintain a clinical record for each patient that must include the patient’s identifying information, clinical...
Confidentiality and Reporting - Or. Admin. R. 411-045-0100 Each Program of All-Inclusive Care for the Elderly (PACE) must have written policies and procedures to assure that participants’ clinical...
Disclosure and certification of records and reports; rules - Or. Rev. Stat. §432.121 It is unlawful for any person to allow an unauthorized person to inspect, disclose, or copy information from vital records or reports in the...
Disclosure of information; corrections, records, immunity from liability - Or. Rev. Stat. § 431.966 Patient data submitted as part of the prescription monitoring program is considered protected health information and is not subject to disclosure as...
Drug Utilization Review (DUR) - Or. Admin. R. 855-019-0220 Pharmacists must maintain a record for each patient that contains information necessary for the pharmacist to perform a drug utilization review....
Examination, specimens; reports and results - Or. Rev. Stat. § 438.430 A clinical laboratory must report the result of any test, examination or analysis of a submitted specimen submitted to the patient, to the provider...
General Standards - Or. Admin. R. 309-039-0540 Each provider of non-inpatient mental health treatment services are required to meet a number of standards, including: Have written policies and...
General Standards for Delivery of Community Mental Health and Developmental Disability Service Elements - Or. Admin. R. 309-014-0035 All community mental health and developmental disability contractors providing services under a contract with the Oregon Health Authority’s...
Health and Medical Records - Or. Admin. R. 333-076-0690 Birthing Centers must maintain health and clinical records for each client and must store such records to prevent access by unauthorized persons....
Health care provider and state health plan charges - Or. Rev. Stat. § 192.563 A health care provider or state health plan that receives an authorization for disclosure of protected health information may charge a fee associated...
Health: Medical Services - Or. Admin. R. 309-043-0310 All Residential Training Center must meet a number of standards for services, including: Keep all individuals’ medical records confidential...
Individual Rights - Or. Admin. R. 309-032-1515 Every individual receiving mental health community treatment and support services has several rights, including: Choose from available services...
Medical Records - Or. Admin. R. 333-505-0050 Hospitals must maintain medical records for each patient that is admitted.  The record must include the following information: Admitting...
Medical Records - Or. Admin. R. 333-071-0060 All health care facilities must maintain medical records for each patient that is admitted.  The medical record must include the following...
Medical Records - Or. Admin. R. 333-076-0165 All ambulatory surgical centers must maintain a medical record for each patient admitted for care.  Medical records are the property of the...
Medical Records - Or. Admin. R. 333-700-0090 Each renal dialysis facility must maintain complete medical records on all patients; each record must contain sufficient information to identify the...
Oregon Health Plan Prepaid Health Plan Record Keeping - Or. Admin. R. 410-141-0180 Prepaid Health Plans (PHPs) and participating providers must have written policies and procedures to ensure that individually identifiable health...
Oregon Health Plan Primary Care Manager Medical Record Keeping - Or. Admin. R. 410-141-0720 A Primary Care Manager (PCM) is a health care provider that agrees to provide primary care management services to an Oregon Health Plan client...
Patient Medical Records - Or. Admin. R. 847-017-0020 A comprehensive medical record must be maintained for each patient who is evaluated or treated in an office-based surgery setting.  The record...
Patients' Rights - Or. Admin. R. 333-027-0080 Each patient of a home health agency has a number of rights, including the following: To be informed, in advance, about the care to be furnished...
Patient’s Access to Medical Records - Or. Admin. R. 847-012-0000 A patient or his or her personal representative has the right to request access to all or part of the patient's protected health information in the...
Policy - Or. Admin. R. 309-012-0070 A patient utilizing Mental Health Services via the Addictions and Mental Health Division of the Oregon Health Authority may review his or her own...
Policy for protected health information - Or. Rev. Stat. §192.553 It is Oregon's policy that an individual has the right to have his or her protected health information safeguarded from unlawful use or disclosure,...
Policy for protected health information - Or. Rev. Stat. §192.553 Oregon’s policy is that individual health information must be protected from unlawful use or disclosure.  It also provides that an...
Records of Care Practice Standards - Or. Admin. R. 332-025-0110 Licensed direct entry midwives must maintain complete and accurate written records of each mother and baby, including a description of the care...
Required record keeping; audit - Or. Rev. Stat. § 410.480 Each authorized agency and service provider for Oregon Project Independence shall maintain books, records, documents and accounting procedures which...
Requirements for Financial, Clinical and Other Records - Or. Admin. R. 410-120-1360 Medicaid participating providers must maintain financial and clinical records.  The records must be well documented and be complete before...
Requirements for Financial, Clinical and Other Records - Or. Admin. R. 333-004-0120 The Office of Family Health is responsible for analyzing and monitoring the operation of the Family Planning Expansion Program and for auditing and...
Residents’ Rights, Generally - Or. Admin. R. 411-085-0310 All residents in a nursing facility have the following rights: To be fully informed of one’s health and medical status; To be fully...
Safety: Individual Records - Or. Admin. R. 309-043-0370 A record must be maintained for each individual receiving services in a Residential Training Center.  The record must include the individual...
Standards and Practices for Care and Services - Or. Admin. R. 309-040-0390 Adult Foster Homes must comply with a number of standards for care and services, including the following: Maintain a copy of medication,...
Standards for Approval of Regional Acute Care Psychiatric Service - Or. Admin. R. 309-032-0870 In order to be granted approval for operation, regional acute care psychiatric services must comply with the following requirements: Maintain...
Standards of Care for Contraceptive Management Services - Or. Admin. R. 333-004-0060 Providers participating in the Family Planning Expansion Program must agree to provide contraceptive management services according to the following...