Series Title (Agency Series #): Description, Retention (Legal Citation)

Encounter Records (DOH13-002): Documents client information and services from field teams for entry into the electronic medical records system. Includes encounter forms indicating client demographic information, and check-off boxes for data entry indicating services provided during the particular visit.
Retention: Retain until entered and verified in system. (2009-0001/001)

Healthy Families Screening Records (DOH13-004): Documents the client eligibility screening process for Health Families Oregon services. Records may include but are not limited to Welcome to Healthy Families Oregon consents, New Baby Questionnaires (NBQ), New Baby Scoring Sheets, and related supporting documentation.
Retention: Retain 10 years. (OAR 410-141-3520(10))

Health Service Records: Field Teams (DOH13-003): Records documenting field services provided to clients. Services may include physicals, management of acute illness and injury, immunizations, family planning and reproductive health care, health education and promotion activities, and mental health services. Records 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; a history of previous service; referrals; testing and evaluation reports; treatment plans; progress notes; enrollment, fee, and billing records; legal records; permission to treat; medical assessment including laboratory and other tests, emergency room services, and medication and prescription records; reports; and other related data. Access to these records may be exempt from disclosure by ORS 179.505; ORS 192.502(2).
Retention: Retain 10 years after last service date. (OAR 166-150-0065(20); OAR 410-141-3520(10)) Retention updated 09/10/2018

Referral Records (DOH13-005): 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 client's chart record.
Retention: If services provided: add referrals to the client's chart; all other cases: Retain 2 years. (OAR 166-150-0065(15))

Note - Maternal Child Family Health was formerly known as Early Childhood Services