Code of Colorado Regulations
1000 - Department of Public Health and Environment
1011 - Health Facilities and Emergency Medical Services Division (1011, 1015 Series)
6 CCR 1011-1 Chapter 22 - BIRTH CENTERS
Part 11 - CLIENT RECORDS
Universal Citation: 1000 CO Code Regs 11
Current through Register Vol. 48, No. 6, March 25, 2025
11.1 The facility shall develop and follow client health records policies and procedures. Such policies and procedures shall be approved by the governing body and ensure such records are:
(A) Legible, uniform, complete, and accurate for every client from registration through conclusion of postpartum appointments and include information in accordance with national birth center standards and this Part 11.
(B) Readily accessible to clinical providers, auxiliary staff, and clients.
(C) Maintained in a system that provides for safe storage, retrieval, privacy, and security in accordance with national birth center standards and all applicable state and federal laws and regulations.
(D) Standardized with regard to the methodology for recording information.
(E) Retained as follows:
(1) For persons age 18 years or older before registration as a client of the facility, health information records shall be preserved as original records, on microfilm, or as electronic records for no less than seven years after the most recent client care encounter, after which time records may be destroyed at the discretion of the facility.
(2) For persons under 18 years of age at registration as a client of the facility, health information shall be preserved until 10 years after the client's 18th birthday.
11.2 Each client's record, including each newborn's client record, shall be available separately and include complete health information from the time of registration through conclusion of postpartum appointments.
(A) All entries into the record shall be dated, timed, and signed by the appropriate personnel.
(B) All orders for diagnostic procedures, treatments, and medications shall be signed by the clinical provider or other authorized licensed practitioner submitting them.
(C) The record shall contain accurate documentation of significant clinical information pertaining to the client and newborn sufficiently detailed and organized in such a manner to enable:
(1) Another practitioner to assume care of the client or newborn at any time.
(2) Evaluation of the quality of client care as part of the facility's quality management program.
(3) Clinical providers and auxiliary staff with the appropriate clinical privileges to utilize the record to instruct the client and family members.
(4) Clinical providers and auxiliary staff with the appropriate clinical privileges to determine risk factors throughout the pregnancy, labor, delivery, and postpartum period.
(D) Identify the family member or support person, as designated by the registered client, who will care for the newborn in the event that the birthing client and newborn are separated, if available.
(E) Newborn records shall include, at a minimum:
(1) Date and time of birth, birth weight and length, period of gestation, sex, and condition of infant on delivery (including Apgar and any resuscitative measures taken).
(2) Record of administered medications and immunizations.
(3) Physical examination at birth and at discharge.
(4) Results of newborn screening in accordance with national birth center standards and state laws and regulations, or documentation of the newborn's parent or guardian declining such tests.
(5) Newborn monitoring record.
(6) Copy of birth certificate worksheet.
(7) Any complications, referrals, and transfers.
(8) Discharge summary.
11.3 Central Log. The facility shall maintain a log for registering client admissions and births, with information about the birthing client and the newborn. The log shall include the following, as applicable:
(A) Admitted Client.
(1) Name.
(2) Date of delivery.
(3) Time of delivery.
(4) Type of delivery.
(5) Transfer information, if applicable:
(a) Mode of transfer, i.e, EMS or other.
(b) Reason for transfer.
(c) Outcome after transfer.
(B) Newborn Client.
(1) Name, if available.
(2) Sex.
(3) Weight.
(4) Gestational age.
(5) Apgar score.
(6) Transfer information, if applicable:
(a) Mode of transfer, i.e, EMS or other.
(b) Reason for transfer.
(c) Outcome after transfer.
11.4 Access to Records
(A) The facility shall:
(1) Provide a copy of the newborn's records to a pediatric care provider upon request by the client or the provider.
(2) Comply with the provisions of 6 CCR 1011-1, Chapter 2, Part 6, Access to Client Records, for all records.
Disclaimer: These regulations may not be the most recent version. Colorado 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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