Current through February, 2024
(a) There shall be
available sufficient appropriately qualified staff and necessary supporting
personnel to facilitate the accurate processing, checking, indexing, filing and
prompt retrieval of records and record data.
(b) All patient records shall be confidential
and are the property of the facility which shall secure them against loss,
destruction, defacement, tampering, and use by legally unauthorized
persons.
(c) Patient records shall
contain the following:
(1) Prior to delivery,
the patient record shall contain the following:
(A) Sufficient history, physical examination,
x-ray, and laboratory data to support the decision to utilize the birthing
facility. The laboratory data must include an Rh factor determination, as well
as the result of a serological test for syphilis.
(B) Evidence of a search for any special
hazards which might confront the patient and evidence of preparation to handle
same should they develop.
(C) An
informed consent form signed by the patient or her guardian.
(2) During and after delivery the
patient record shall contain:
(A) A record of
all medications including administration of Rh immune globulin, obstetrical and
anesthetic techniques used, as well as any surgical procedures.
(B) Record of vital signs monitoring during
all stages of delivery.
(C) The
condition and description of the placenta.
(D) Condition of the mother and child at the
time of discharge or transfer.
(3) The medical record shall be kept current
at all times so that in the event of transfer to another facility no time will
be lost bringing records up-to-date.
(d) Newborn records shall include the
following:
(1) Date and hour of birth; birth
weight and length; period of gestation; sex; and condition of infant on
delivery. An Apgar score shall be required.
(2) Mother's name, Social Security number,
and facility case number.
(3)
Record of opthalmic prophylaxis.
(4) Record of any resuscitative procedures
used.
(5) Record of Vitamin K
administration, and any other medication which were administered.
(6) Appropriate physical examination at birth
and at time of discharge.
(7)
Record of phenylketonuria, thyroid screening test, and other lab
results.
(e) A daily log
with monthly summaries of all procedures performed in the facility and
disposition of the patients shall be kept by the facility.
