Series Title (Agency Series #): Description, Retention (Legal Citation)
Complaint Log (DOH36-010): Record of all complaints received at primary care clinics. Used to report complaints to Oregon Medical Assistance Program (OMAP) on a quarterly basis and to document compliance with HIPAA complaint process. Log shows date of complaint, complainant's name, description of complaint, and related information.
Retention: Retain 6 years. (45 CFR 164.530(J))
Correspondence: Records that: 1. document communications created or received by an agency AND 2. directly relate to an agency program or agency administration AND 3. are not otherwise specified in the Multnomah County Retention Schedules. Records may include but are not limited to letters, memoranda, notes and electronic messages that communicate formal approvals, directions for action, and information about contracts, purchases, grants, personnel and particular projects or programs.
Retention: File with the associated program or administrative records. Communications not meeting the above criteria do not need to be filed and may be retained as needed. (OAR 166-150-0005(10)) Updated 01/08/2018
Daily Appointment List (DOH36-013): Documents all clinic appointments. Shows date and time of appointment, client's name, provider name, reason for appointment, and related information.
Retention: Retain 1 year. (MOAR 166-150-0005(5))
Encounter Records (DOH36-002): Documents client information and services provided at each clinic visit for entry into the Health Information System. Includes encounter forms indicating client demographic information, and check-off boxes for data entry indicating services provided during the particular site visit.
Retention: Retain 3 months. (2009-0001/033)
Health Service Records (DOH36-001): Records documenting primary care clinic comprehensive primary care services which 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: For paper charts: Retain 10 years after last entry. For EHR: Retain 10 years after last service. (MOAR 166-150-0065(20); OAR 410-141-3520(10)) Retention updated 12/10/2018
Immunization Records - VARS (DOH36-003): Series documents immunizations received by clinic patients. Record is usually the county Vaccine Administration Record (VAR), but may include any records which document the consent to and administration of immunizations. Does not include ITARS reports. Information includes date, patient name and personal information, identification number, income and insurance information, signature and date of consent, description and date of immunization(s), and signature and date of immunization administrator. Access to these records may be exempt from disclosure by ORS 179.505; ORS 192.502(2).
Retention: Retain 10 years. (MOAR 166-150-0065(10a,11)) Updated 12/10/2018
Financial Eligibility Records (DOH36-011): Documents used for screening of clients to determine program eligibility for primary care services, Medicaid, and any other public or private financial assistance programs and financial documentation required by grant funding. The records include all DHS Medicaid applications, clinic registration forms, other financial assistance applications and all supporting documents (including income documentation, insurance cards, address, social security numbers and cards, citizenship, and identification used in determining eligibility for programs). Also includes mailing lists and sign in lists that contain client names.
Retention: Retain 10 years. (45 CFR 164.530(j), OAR 410-141-3180(12)) Updated 1/2/2019
No Service Client Intake Records (DOH36-015): Documents assessment of clinic patients for whom no county services are provided. Records include referral information, patient information, medical information, and clinic assessment.
Retention: Retain 10 years (MOAR 166-150-0065(20); OAR 410-141-3520(10)) Retention updated 10/29/2018