Code of Massachusetts Regulations
105 CMR - DEPARTMENT OF PUBLIC HEALTH
Title 105 CMR 130.000 - Hospital Licensure
Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES
Section 130.627 - Records
Universal Citation: 105 CMR 130.000 MA Code of Regs 130.627
Current through Register 1531, September 27, 2024
(A) Maternal Record . The obstetrics service shall establish and maintain a system for obtaining prenatal records or summaries of records of patients at 24 weeks of pregnancy (with updates as warranted in accordance with hospital policy) and for making them available to the staff of the labor and delivery unit when the patient is admitted for delivery. Such records shall be maintained as part of the mother's permanent record.
In addition to the requirements for all hospital patient records, the mother's record shall include:
(1) Mother's medical and obstetric history
including prenatal course.
(2)
Antenatal blood serology, Rh factor, blood type, HBsAg test, rubella antibody
and Group B streptococcal culture results. In addition, results of maternal HIV
testing, if applicable.
(3)
Admission obstetrical examination including the condition of both mother and
fetus.
(4) Complete description of
progress of labor and delivery, signed by the attending physician, or certified
nurse midwife, including reasons for induction and operative
procedures.
(5) Type of
medications, analgesia and anesthesia administered to the patient during labor
and delivery.
(6) Signed report of
qualified obstetric or other consultant when such service has been
obtained.
(7) Names and credentials
of all those present during delivery.
(8) Description of postpartal course,
including complications and treatments, signed by the attending physician or
certified nurse midwife.
(9)
Medications, including contraceptives, prescribed at discharge.
(10) Infant's condition at birth including
gestational age, weight, Apgar score, blood type, and results of initial
physical assessment.
(11) Nursing
assessment, diagnosis, interventions and teaching.
(12) Method of infant feeding and infant
feeding plan of care and progress and documentation of lactation care and
services provided.
(13) If neonatal
death occurs, cause of death, assessment of the family's coping mechanisms and
plans for follow-up and/or referral of the family.
(B) Newborn Record. In addition to the requirements for all patient records, the newborn record shall include:
(1) Significant maternal
diseases.
(2) Mother's obstetric
history including estimated date of confinement and prenatal care
course.
(3) Maternal antenatal
blood serology, typing, Rh factors, rubella antibody titer, coombs test for
maternal antibodies if indicated, and prenatal HBsAg test results.
(4) Results of anysignificant prenatal
diagnostic procedures including genetic testing and/or chromosomal
analysis.
(5) Complications of
pregnancy or delivery.
(6) Duration
of ruptured membranes.
(7)
Medications, analgesic and/or anesthesia administered to the mother.
(8) Complete description of progress of labor
including diagnostic tests, treatment rendered and reasons for induction or
operative procedures.
(9) Date and
time of birth.
(10) Cause of death
if it occurs.
(11) Condition of the
infant at birth including Apgar score, resuscitation, time of sustained
respirations, description of congenital anomalies, gestational age, head
circumference, length, weight, pathological conditions and
treatments.
(12) Number of cord
vessels and description of any placental anomalies.
(13) Written verification of eye prophylaxis,
vitamin K and mandated screening tests, including time and date.
(14) Infant Feeding.
(a) Method of feeding including feeding plan
of care.
(b) Documentation of at
least two successful feedings, for both breastfeeding and formula fed
infants.
(15) Report of
infant's initial medical examination within 24 hours of birth, signed by the
infant's attending physician or his or her physician designee or neonatal nurse
practitioner.
(16) Informed consent
for circumcision or any other surgical procedures.
(17) Physician progress notes written in
accordance with hospital policy.
(18) A report of discharge examination signed
by attending physician, certified nurse midwife pediatric nurse practitioner or
neonatal nurse practitioner within 24 hours of discharge.
(19) Nursing assessment, diagnosis,
interventions and teaching.
(20)
Documentation that hearing screening has been performed, screening results and
referral, if any. If a referral is made, the medical record shall document the
date, time and location of the follow-up appointment.
(21) Discharge instruction sheet including
feeding plan, referrals and follow-up care signed by the infant's
practitioner.
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