Kansas Administrative Regulations
Agency 100 - KANSAS STATE BOARD OF HEALING ARTS
Article 28b - INDEPENDENT PRACTICE OF MIDWIFERY
Section 100-28b-14 - Patient records
Universal Citation: KS Admin Regs 100-28b-14
Current through Register Vol. 43, No. 12, March 20, 2024
(a) Each licensee shall maintain an adequate health care record for each patient for whom the licensee performs a professional service.
(b) Each health care record shall meet the following requirements:
(1) Contain only those
terms and abbreviations that are or should be comprehensible to similar
licensees;
(2) document adequate
identification of the patient;
(3)
document all professional services provided or recommended and the date on
which each professional service was provided or recommended;
(4) document all clinically pertinent
information concerning the patient's condition;
(5) document all identifiable risk
assessments performed on the patient;
(6) document all examinations, vital signs,
and tests obtained, performed, or ordered, and the findings and results of
each;
(7) document all medications
prescribed, dispensed, or administered, the time each medication was
prescribed, dispensed, or administered, and the dose and route of each
medication;
(8) document the
patient's response to all professional services performed or
recommended;
(9) document all
instruction and education provided to the patient related to the childbearing
process;
(10) document the date and
time of the onset of labor;
(11)
document the course of labor, including all examinations and pertinent
findings;
(12) document the date
and exact time of birth, the presenting part of the newborn's body, the
newborn's sex, and the newborn's Apgar scores;
(13) document the time of expulsion and the
condition of the placenta;
(14)
document the condition of the patient and newborn, including any complications
and action taken;
(15) contain the
results of all postpartum and newborn examinations;
(16) document all professional services
provided to the newborn, including prescribed medications and the time, type,
and dose of eye prophylaxis;
(17)
contain documentation of all consultation and collaboration with a physician
concerning the patient;
(18)
contain documentation of each referral, transfer, and transport to a medical
care facility, including the reasons for each referral, transfer, or transport
to a medical care facility;
(19)
contain all written instructions given to the patient regarding postpartum
care, family planning, care of the newborn, arrangements for metabolic testing,
immunizations, and follow-up pediatric care; and
(20) contain all pertinent health care
records received from other health care providers.
(c) Each entry in the health care record shall meet the following requirements:
(1) Be
legible; and
(2) be authenticated
by the person making the entry. Each authentication in the health care record
for an entry documenting professional services provided by an individual
licensed to engage in the independent practice of midwifery shall include the
letters "CNM-I after the licensee's name.
(d) For the purposes of the independent practice of midwifery act and this regulation, an electronic patient record shall be deemed a written patient record if both of the following conditions are met:
(1) Each entry in the electronic
record is authenticated by the licensee.
(2) No entry in the electronic record can be
altered after authentication.
Disclaimer: These regulations may not be the most recent version. Kansas 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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