1. (1) Record keeping must conform and adhere to Federal, state, and local laws and regulations.
2. (2) Records must record history taken; procedures performed and tests administered; results obtained; conclusions and recommendations made. Documentation may be in the form of a "SOAP" (Subjective Objective Assessment Plan) note, or equivalent.

3. (3) Records and documentation must:

   1. (a) Be accurate, complete, and legible;
   2. (b) Be printed, typed or written in ink;
   3. (c) Include the documentor's name and professional titles;
   4. (d) Stamped identification must be accompanied by initial or signature written in ink.

4. (4) Corrections to entries must be recorded by:

   1. (a) Crossing out the entry with a single line which does not obliterate the original entry, or amending the electronic record in a way that preserves the original entry; and
   2. (b) Dating and initialing the correction.
5. (5) Documentation of clinical activities may be supplemented by the use of flowsheets or checklists, however, these do not substitute for or replace detailed documentation of assessments and interventions.

Statutory/Other Authority

ORS 681.420(5) & 681.460

Statutes/Other Implemented

ORS 681.420

History

SPA 1-07, f. & cert. ef. 2-1-07
SPA 4-2006, f. & cert. ef. 11-3-06
SPA 2-2004, f. & cert. ef. 5-26-04