Board of Chiropractic Examiners, Chapter 811
Rule Caption: Records 811-015-0005
Adm. Order No.: BCE 5-2013
Filed with Sec. of State: 11-27-2013
Certified to be Effective: 11-27-13
Notice Publication Date: 9-1-2013
Rules Amended: 811-015-0005
Subject: Requires retention of written file reviews similar to other requirements for maintaining other patient records
Rules Coordinator: Kelly J. Beringer—(503) 373-1573
(1) It will be considered unprofessional conduct not to keep complete and accurate records on all patients, including but not limited to case histories, examinations, diagnostic and therapeutic services, treatment plan, instructions in home treatment and supplements, work status information and referral recommendations.
(a) Each patient shall have exclusive records which shall be sufficiently detailed and legible 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 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.
(2) Practitioners with dual licenses shall indicate on each patient’s records under which license the services were rendered.
(3) A patient’s original records shall be kept by the Chiropractic physician a minimum of seven years from the date of last treatment. There is no requirement to keep any patient records older than seven years; except if the patient is a minor, the records shall be kept seven years or until the patient is 18 years of age, whichever is longer.
(a) If the treating chiropractic physician is an employee or associate, the duty to maintain original records shall be with the chiropractic business entity or chiropractic physician that employs or contracts with the treating chiropractic physician.
(b) Chiropractic physicians 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, he/she 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 his/her clinic, a notation shall be made in the patient’s file or in an office log where the films are located and chiropractic physician must ensure those films are available for release if requested by the patient.
(5) The responsibility for maintaining original patient records may be transferred to another chiropractic business entity or to another chiropractic physician as part of a business ownership transfer transaction.
Stat. Auth.: ORS 684
Stats. Implemented: ORS 684.155
Hist.: 2CE 1-1978, f. 6-16-78, ef. 7-1-78; CE 5-1995, f. & cert. ef. 12-6-95; CE 4-1997, f. & cert. ef. 11-3-97; BCE 3-2000, cert. ef. 8-23-00; BCE 2-2006, f. & cert. ef. 2-9-06; BCE 5-2013, f. & cert. ef. 11-27-13
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