OAC 310:662-3-5 — Clinical records

What this rule requires your agency to do

• 1The agency must establish and maintain a complete, timely, accurately documented, and readily accessible clinical record for each client, keep it confidential per written policies, store it in a locked area, and limit access to authorized personnel (a).(OAC 310:662-3-5 — Clinical records)
• 2Upon discharge, the agency must document a summary of services provided and the client's status at discharge and provide a copy to the client's physician (e)(4).(OAC 310:662-3-5 — Clinical records)
• 3Physician orders must be sent by the agency within 10 days to the ordering physician to be signed and returned timely (e)(3).(OAC 310:662-3-5 — Clinical records)
• 4Where skilled care or physician-ordered personal care is provided, the record must also include the client physician's name and phone, signed/dated clinical notes documenting services/treatments/medications and client response (e)(1)-(2).(OAC 310:662-3-5 — Clinical records)
• 5Each clinical record must contain identifying information (including emergency phone numbers), an initial assessment with health history and current findings, a description of functional limitations/activity restrictions, documentation of any condition change, and dated service notes with the provider's name, title, and signature (d).(OAC 310:662-3-5 — Clinical records)
• 6The agency must release clinical records only upon written client/guardian consent, court order, or as otherwise authorized by law, and must let former clients obtain copies of their records as allowed by law (b).(OAC 310:662-3-5 — Clinical records)
• 7The agency must retain clinical records at least five years beyond the date the client was last seen, or longer if required by law (c).(OAC 310:662-3-5 — Clinical records)