Current through November 28, 2024
(a) A birth center shall keep records for all
clients admitted. Originals, or accurate reproductions of the contents of the
originals, of all records, including x-rays, must be maintained in a form that
is legible and uniform, contains complete and accurate client and newborn
information, and fully describes continuity of care. The birth center shall
ensure that these records are readily available upon the request of the
physician, consulting physician, midwife, or the department or, upon the
client's written request, to other practitioners. The birth center shall
maintain each record in a system that protects confidentiality of the
information contained in its records, that provides for proper storage, easy
retrieval, and prevention of loss, and that protects against the use or
disclosure of protected health information except as required or permitted by
45 C.F.R. Part 160, subpart C, and 45 C.F.R. Part 164, subpart E, adopted by
reference in
7
AAC 12.770(d). The birth center shall
develop, for use by the clinical staff, a form for providing information
necessary for a transfer of a client or newborn to a hospital. The birth center
shall ensure that a copy of the prenatal record is available before and during
labor. The birth center shall ensure that a copy of the complete record for a
client or newborn is provided at the time of any transfer or
referral.
(b) Each medical record
must include
(1) an identification sheet that
includes
(A) the client's
(ii) medical record number;
(iii) address on admission;
(B) the date of admission;
(C) the name, address, and telephone number
of a contact person;
(D) proof that
the birth center provided the client a complete orientation in accordance with
7
AAC 12.403(d);
(E) a plan for payment for
services;
(F) the client's social,
family, medical, reproductive, nutritional, and behavioral history;
(G) the results of an initial physical
examination;
(H) the results of a
risk assessment conducted upon admission in accordance with the standards
developed under
7
AAC 12.403(f);
(I) evidence of appropriate referral for an
ineligible client, including the report completed during initial
screening;
(J) the results of
continuous periodic prenatal examination, including evaluation of risk factors
and risk status in accordance with the standards developed under
7
AAC 12.403(f); and
(K) information regarding instruction and
education provided, including nutritional counseling, changes in pregnancy,
self-care in pregnancy, orientation to health records, understanding of
findings on examinations and laboratory tests, preparation for labor, sibling
preparation, and newborn assessment and care;
(2) an order sheet that includes medication
and treatment, signed by a midwife or another practitioner who ordered the
medication or treatment;
(3) notes
entered by the clinical staff, including
(A)
an accurate record of care given;
(B) a record of pertinent observations and
responses to treatment of the client including psychosocial and physical
manifestations;
(C) an assessment
at the time of admission;
(E) the name,
dosage, and time of administration of a medication or treatment, the route of
administration and site of injection of a medication if other than by oral
administration, the client's or newborn's response, and the signature of the
person who administered the medication or treatment;
(F) documentation that initial bloodspot
screening was completed for the newborn;
(G) documentation on admission of the
client's vital signs, including temperature, pulse, respiration, and blood
pressure;
(H) documentation of the
client's vital signs at least every four hours during the latent phase of
labor;
(I) documentation of any
change in vital signs in the presence of risk factors, including rupture of
membranes and borderline blood pressure;
(J) documentation on admission of uterine
contractions;
(K) documentation of
fetal heart tones on admission and periodically during the latent phase of
labor;
(L) documentation of fetal
heart tones at least every 30 minutes during the active phase of
labor;
(M) documentation of fetal
heart tones at least every 5 to 15 minutes when pushing is occurring;
(N) documentation of fetal heart tones after
rupture of membranes;
(O)
documentation of the client's vital signs within the first hour after
delivery;
(P) documentation of the
newborn's vital signs, including tone color, within the first hour after
delivery; and
(Q) documentation of
at least one additional set of client and newborn vital signs before discharge
from the birth center;
(4) treatments, consultations, and laboratory
reports;
(5) informed consent forms
signed by the client and midwife;
(6) monitoring of progress in labor with
ongoing assessment of client and fetal reaction to the process of
labor;
(8) the record of a
neonatal physical examination, including Apgar scores, client and newborn
interaction, prophylactic procedures, accommodation of the newborn to
extrauterine life, and blood glucose if clinically indicated;
(9) any consultation regarding referral and
transfer for any client or neonatal problem that elevates risk status under the
standards developed under
7
AAC 12.403(f);
(10) evidence of screening for gram positive
Group B
Streptococcusby an approved laboratory, Group B
Streptococcustreatment as necessary, information provided to
the client regarding Group B
Streptococcus, and monitoring
after delivery of each newborn born to a client who tests positive for Group B
Streptococcusor to a client with unknown status;
(11) ongoing physical assessment of the
client and newborn during recovery;
(12) a summary of the progress of
labor;
(13) a discharge summary for
the client and the newborn;
(14) a
plan for newborn health supervision, completion of the initial bloodspot
screening, and required follow-up screening, including the provision for
newborn hearing screening; and
(15)
follow-up postpartum evaluation of the client, counseling for family planning,
and other services.
(c)
The birth center shall maintain procedures to protect the information in
medical records from loss, defacement, tampering, or access by unauthorized
persons.
(d) The birth center shall
index and file records using a uniform system that allows for efficient
retrieval according to a single identifying number for each client.
(e) A transfer summary, signed by the midwife
or collaborating physician, must accompany the client or newborn if the client
or newborn is transferred to a hospital. The transfer summary must include
essential information regarding the client's or newborn's diagnosis, condition,
medications, treatments, dietary requirements, known allergies, and treatment
plan.
(f) The birth center shall
establish and maintain a system for periodic review of the birth center's
record-keeping system and its policies and procedures for the maintenance,
storage, retrieval, and retirement of client and newborn records.
(g) The birth center shall appoint an
individual who is a member of the clinical or support staff to be responsible
for the processing, maintenance, and storage of records, and who will ensure
that access to records is limited to persons authorized to review those
records.
(h) The birth center shall
retain and preserve records that relate directly to the care and treatment of a
client or newborn for at least seven years after discharge. However, the
records of a client who is under 19 years of age must be kept until at least
two years after the client has reached 19 years of age or until seven years
after discharge, whichever is longer. The birth center shall retain and
preserve records consisting of x-ray film for at least five years.
Authority:AS
47.32.010
AS 47.32.030
AS 47.32.100
AS
47.32.110
