Code of Colorado Regulations
700 - Department of Regulatory Agencies
739 - Division of Professions and Occupations - Office of Direct-Entry Midwifery Registration
4 CCR 739-1 - MIDWIVES REGISTRATION RULES AND REGULATIONS
Section 4 CCR 739-1.9 - MINIMUM PRACTICE REQUIREMENTS REGARDING RECORD KEEPING

Universal Citation: 4 CO Code Regs 739-1 ยง 9

Current through Register Vol. 47, No. 17, September 10, 2024

The purpose of this Rule is to clarify the minimally appropriate records of direct-entry midwifery related activity that are required pursuant to sections 12-225-106(5)(a) and 25-4-201, C.R.S.

A. The direct-entry midwife shall keep appropriate records on all clients. All records shall, at a minimum:

1. Be accurate, current, and comprehensive, giving information concerning the condition and care of the client and associated observations;

2. Provide a record of any problems that arise and the actions taken in response to them;

3. Provide evidence of care required, interventions by professional practitioners and client responses;

4. Include a record of any factors (physical, psychological or social) that appear to affect the client;

5. Record the chronology of events and the reasons behind decisions made;

6. Provide baseline data against which improvement or deterioration may be judged;

7. Reflect any recommendation for, or initiation of, transfer to a hospital;

8. Have a signature and date for each entry; and

9. All records shall be made available to the receiving health care provider in the event of transfer of care or the transport of client or newborn.

B. The client records shall include, at a minimum:

1. The risk assessment as required in section 12-225-106(11), C.R.S.;

2. Mandatory disclosure form;

3. Informed consent form and emergency plan;

4. Assessments, interventions and recommendations for each prenatal visit;

5. Progress of labor and maternal assessments during labor;

6. Fetal assessments during labor;

7. Apgar scores and newborn examination;

8. Administration of any medications and/or intravenous fluids;

9. Refusal of care by the client;

10. Filing the birth certificate as required by section 25-2-112, C.R.S.;

11. Follow-up postpartum visits;

12. Statement of verification that one copy of the record was provided to the client or the health care provider of her choice;

13. Baseline blood pressure determined prior to the end of the second trimester or upon the initial visit if such visit occurs subsequent to the second trimester; and

14. Documentation of laboratory referral for syphilis, HIV, and Group B Streptococci testing, or documentation of the client's refusal for such tests.

C. A copy of the record shall be provided to the client and/or other health care provider(s) at the completion of care or when requested.

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.
This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.