Oregon Administrative Rules
Chapter 331 - OREGON HEALTH AUTHORITY, HEALTH LICENSING OFFICE
Division 840 - STANDARDS OF PRACTICE AND PROFESSIONAL RESPONSIBILITY
Section 331-840-0060 - Client records

Universal Citation: OR Admin Rules 331-840-0060

Current through Register Vol. 63, No. 9, September 1, 2024

(1) Certificate holders must maintain documentation for each client relevant to health history, clinical examinations and treatment, and financial data.

(2) Records must include:

(a) Client's name, address, telephone number and dates of service;

(b) Health history related to sexual-abuse-specific evaluation or treatment plan(s), including referral to other mental health-care provider or physician.

(c) Description of services -- chart notes -- including any complications. Chart notes must include the recorder's initials, certification number and professional title if multiple practitioners provide service to the client.

(3) Certificate holder's name, license number, professional title or abbreviation, and signature or initials somewhere on the documentation as a means of identifying the person who is providing service to the client. This information may be affixed to the record(s) in the form of a professional stamp or handwritten entry.

(4) Client records and documentation must be retained for at least seven years after the certificate holder stops working with the client.

Statutory/Other Authority: ORS 676.560, ORS 676.565 & ORS 675.360-675.410

Statutes/Other Implemented: ORS 676.560, ORS 676.565 & ORS 675.360-675.410

Disclaimer: These regulations may not be the most recent version. Oregon may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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