Or. Admin. R. 166-150-0065 - County Health - Public/Community Health Records
(1)Alcohol and Drug Service Records
Series documents services provided to clients in alcohol and drug
treatment programs. These services may include residential treatment and care,
outpatient services, detoxification, DUII education and treatment, sex offender
treatment, methadone treatment, and other services. Series may consist of
clinical records or patient files including assessment records, treatment
plans, progress notes, treatment reviews, termination reports, and medical
records. (Minimum retention: 6 years after last service or until 21st
birth-day, whichever is longer)
(2) Board of Health Reports
Series documents the activities of the county health departments such as public
or community health, mental health, environmental health, family mediation,
alcohol and drug, developmental disabilities, deputy medical examiner, and
fiscal administration. Series includes semi-annual reports to the County Board
of Health prepared by the various departments. The reports summarize department
activities, and discuss concerns and problems of future importance. Series may
also contain reports on special topics such as AIDS and other issues. Reports
may be sent to the Board of County Commissioners. (Minimum retention:
(a) Reports filed with County Commissioners:
10 years
(b) Reports not filed with
County Commissioners: Permanent)
(3) Car Seat Rental Service
Records Series documents the rental of car seats for infants and young
children. Information contained in the records may include name, weight, and
date of birth of child; name and address of recipient; signatures; witnesses;
conditions for loan; car seat number; and related documentation. (Minimum
reten-tion:
(a) If car seat returned: Until
return of car seat
(b) If car seat
is not returned: 5 years)
(4)Communicable Disease Intake Report
Series is used to identify persons with communicable diseases such as
sexually transmitted diseases, HIV, tuberculosis, food-borne diseases, and
others. Information contained in the report may include name of disease,
patient identification, name of physician, symptoms, laboratory results, and
other related data. Information from this intake report may be transferred to
the investigation report or the intake report may be attached to the
investigation report. (Minimum retention: 1 year)
(5)Communicable Disease Investigation
Reports Series documents investigations into reports of communicable
diseases. The investigation form is used by nurses to compile information about
persons with a communicable disease. Information contained in the investigation
reports (there are forms for different diseases) may include patient
identification; demographics; sources of report; basis of diagnosis including
clinical data, laboratory data and report, and epi-linkage; infection timeline
indicating exposure and communicable periods; and other related data. The
Notice of a Disease or Condition form may contain disease, patient
identification, date of onset of disease, names and addresses of physician and
person reporting, and other related data. Copies of both forms are sent to the
Oregon Health Division. (Minimum retention:
(a) Investigation Form: 5 years
(b) Notice of a Disease or Condition Form: 3
years)
(6)
Communicable Disease Log Series documents communi-cable diseases by
providing a summary of information taken from the intake report. Information
contained in the log may include type of disease, patient name, date of report,
and other related data. Series is used for quick reference and to compile
statistics. (Minimum retention: 5 years)
(7)Complaint Correspondence
Records document formal and informal complaints involving extended
investigation and/or litigation concerning environmental health issues; staff
or division policies; or other perceived health problems in the community.
Records may include letters, memorandum, hearing transcripts, Board of County
Commissioner minutes, and other records which document or add significant
information to the complaint. (Minimum retention: 10 years after
resolution)
(8)Health
Insurance Portability and Accountability Act (HIPAA) Disclosure Notices
Records document notification to clients about the agency's practices regarding
client medical records and information under HIPAA. Records include
notification forms and related records. (Minimum retention: 6 years after last
service)
(9)HIV Test
Records Series documents the results of anony-mous or confidential HIV
tests. Information contained in the records may include test results,
demographic information, patient history, number of test results, and other
related data. Anonymous testing programs do not give the name of the patient,
and may include only a client number and demographic information such as race,
age, and sex. Confidential programs include the name and address of the patient
which is then kept confidential. (Minimum retention: 2 years)
(10)Immunization and Injection
Records Series documents immunizations received by a patient. Services
may include immunizations for infants, children, and adults; TB skin tests; flu
and pneumonia shots; and overseas immunizations for travelers. Information
contained in the records may include name and date of birth of patient; name,
address, and phone number of parent/ guardian; type of vaccine; dose number;
date; and other related data. Records may include ITARS (Immunization Tracking
and Recall System) documentation. (Minimum reten-tion:
(a) Immunization records: 10 years
(b) ITARS records: 25 years from date of last
service
(c) Other records: 6 years
after last service or until 21st birthday, whichever is longer)
(11)Immunization
Authorization Records Series documents authorizations and
parental/guardian consent for children and other patients to receive
immunizations. Information contained in the records may include name and
address of person receiving immunization; name and signature of patient or
parent/guardian; date vaccinated; manufacturer and lot number of vaccine; site
of injection; signature of provider; and other related data. (Minimum
retention: 10 years)
(12)Immunization Cards Series
used to enter information about immunizations given to clients in the county's
immunization database. Information includes type of vaccine, PPD results, and a
clients contraindications of precautions regarding a specific vaccine. Vaccines
include Measles, Mumps, Rubella; Dipheria/Pertussis/Tetanus; Polio; Immune
Globulin; Hepatitis A; Hepatitis B; Haemophilus Influenza Type B; Influenza;
Pneumococcal; and Varicella. (Minimum retention: Until entered into system and
verified)
(13)Interpreter
Service Records Series documents the scheduling of interpreters for
needed county departments, and the services provided for payment purposes.
Records may include interpreter scheduling and request forms, on-call invoices,
timesheets, and related records. (Minimum retention: 2 years)
(14)Laboratory Logs Series
documents laboratory tests per-formed for patients. Types of laboratory tests
may include hematocrits, urinalysis, GC cultures, wet mounts, serologies, blood
typing and Rh factor, and pregnancy tests. Information contained in the logs
may include name of patient, date, name of test, results of test, date of
results, name of person who performed the test, and other related data.
(Minimum retention: 2 years)
(15)Maternal-Child Health
(Children and Family) Service Referral Reports Series documents referrals
involving maternal-child health concerns from other providers, such as
physicians or hospitals. Information contained in the reports may include the
name and address of the family; name and age of child; reason for referral;
history and concerns; and any actions or services provided by the referral
agency. If services are provided to the patient, the referral report becomes
part of the Public Health Service Records. (Minimum retention:
(a) If services provided: Transfer to Public
Health Service Records
(b) All
other cases: 2 years)
(16)Medicaid Financial Screening
Records Series documents the screening of clients who appear eligible
for Medicaid for a final eligibility determination by Adult and Family Services
(AFS). Records contained in the series include Medicaid Financial Screening
Form, which indicates the client's income status, lists of clients, and AFS
forms which indicate the client's personal data as it applies to eligibility,
client's understanding of rights and responsibilities, effective date of
eligibility pending client's provision of appropriate documentation, narrative
notes completed by screeners, information on insurance already held by client,
and information relating to injuries caused by automobile accidents. (Minimum
retention: 2 years)
(17)Medical Examiner Case Files
Series documents investigations into deaths by the county medical examiner,
coroner, or other designated official. Series contains records on any deceased
person that requires medical examiner involvement. Records include the autopsy
report and the medical examiners report. Records may also include other data
that is considered significant as to the manner of death such as a police
report, family interview, personal identification, and disposition of unclaimed
funds. (Minimum retention:
(a) Pre-1965
Coroner's Reports: Permanent
(b)
Post-1965 case files: 25 years
(c)
No case file developed: 5 years)
(18)Pharmacy Logs Series
documents the dispensing or issuing of drugs such as birth control pills
or antibiotics. Information contained in the log may include identification
number, client name, date, name of drug, dosage, number of pills, initials of
person dispensing the drug, and other related data. (Minimum retention: 3
years)
(19) Public Health
Service Index (Master Patient Index) Cards Series provides an index to
patients and the services provided to them. Information contained in the index
may include patient name, address, and birthdate; services provided; program;
first date of service; dates admitted and discharged; health record number; and
other related data. Separate indexes may be kept for different programs.
(Minimum retention: 25 years after date of last service)
(20)Public Health Service
Records Series documents the services given to a patient. Series
contains records for patients in specialized programs such as the Women,
Infants, and Children (WIC) nutrition program; clinical services (including
tuberculosis, HIV, sexually transmitted diseases, hepatitis, and
immunizations); dental services; sero-wellness; family planning and pregnancy
testing; car-seat rental; maternal-child health nursing services concerning
high risk pregnancies, high risk infants, or young children with major health
problems or disabilities; and public health field nursing services which may
include counseling, teaching, and referral services concerning maternal and
child health care, pregnancy and postpartum health, child development,
parenting skills, and Sudden Infant Death Syndrome (SIDS). Series may include
correspondence; reports; professional notations; laboratory reports; treatment
and x-ray authorizations; release of information; clinical or medical records
including client identification, progress notes, and records of visits; and
other related data. (Minimum retention:
(a)
Outpatient physical therapy and speech-language pathology service records: 6
years after last service or until 21st birthday, whichever is longer
(b) Dental patient records: 7 years after
last service
(c) All other
outpatient service records: 6 years after last service
(d) Counties participating in the Medicare
Advantage Program, retain all records 10 years after contract expires (42CFR
422.504)
(21)Sero-Positive Wellness Program
Charts Series documents the services and treatment provided to people
with HIV. Information contained in the charts may include a record of service
and treatment, laboratory results, work plans, and other related data. The
records are used for counseling and education purposes. The records may be
transferred to the Oregon Health Division upon closure, or they may become part
of the patient's clinical file in the Public Health Service Records. (Minimum
retention: 6 years after last service)
(22)Sexually Transmitted Disease
Epidemiological Reports Series documents the investigation into sexually
transmitted diseases. Information is compiled on two forms. The Confidential
Sexually Transmitted Disease Case Report contains information such as patient
identification; diagnosis, site, and treatment of disease; provider name and
address; and other related data. The Field Report (a form provided by the U.S.
Department of Health & Human Services) contains information such as patient
identification; exposure, referral, examination, and treatment information;
interview notes; and other identifying or medical information. Copies of both
records may be forwarded to the Oregon Health Division. Individuals who are
seen and treated at STD clinics will have a clinical file in the Public Health
Service Records. (Minimum retention:
(a) If
patient is treated: transfer to Public Health Service Records
(b) If patient is not treated: 5
years)
(23)Tuberculosis Client Records
(Tuberculosis Registry) Series documents patients with active and inactive
cases of tuberculosis. Records may contain information such as patient
identification; source of specimen; drug treatment information such as dosage
and dates; dates the case was opened and closed; epidemiological reports; and
other related data. (Minimum retention:
(a)
Active cases where death date is known: retain for life of individual
(b) Active cases where death date
is unknown: retain for 70 years after last service
(c) Inactive cases with patients on
preventive drug therapy: 6 years after last service)
(24)Tuberculosis Negative Cases
Epidemiological Reports Series documents service to patients with
negative tuberculosis tests, that is, patients with positive skin tests who do
not have the disease and have not received treatment. Information contained in
the reports may include patient name, date, x-ray report, skin text results,
and other related data. (Minimum retention: 2 years; destroy reports when
recorded in Tuberculosis Client Records (Registry))
(25)Tuberculosis X-Ray Authorization
Records Series documents authorizations and parental consent for
children and other patients to receive tuberculosis x-rays. Information
contained in the records may include patient identification, demographics, PPD
test results, name of radiology lab, and related documentation. (Minimum
retention: 6 years after last service)
(26)Tuberculosis X-Ray Records
Series documents x-rays used to screen and diagnose cases of tuberculosis.
Records may include registration cards and x-ray film. Information contained in
the records may include patient identification, demographics, medical history,
x-ray results, assessment of condition, treatment plan, drugs ordered, and
related documentation. (Minimum retention:
(a) Active cases where death date is known:
Retain for life of individual
(b)
Active cases where death date is unknown: Retain for 70 years after last
service
(c) Inactive cases with
patients on preventive drug therapy: 6 years after last service)
Notes
Stat. Auth.: ORS 192 & 357
Stats. Implemented: ORS 192.005-192.170 & 357.805-357.895
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