Current through Register Vol. 35, No. 18, September 24, 2024
The facility shall maintain client health records in a
legible, uniform, complete and accurate format that provides continuity and
documentation of maternal and newborn information which is readily accessible
to health care practitioners, while protecting confidentiality, using a system
that allows for reliable and safe storage, retrieval and loss prevention. The
facility must use a record form appropriate for use by the practitioners in the
facility which contains the required information necessary for transfer to an
acute care maternal and newborn hospital.
A. Record contents: Each licensed facility
must maintain a medical record for each client which may be in a paper or
electronic format but which can be easily accessible, copied, provided,
reviewed and transported in the event of any emergency or transfer. Every
record must be accurate, legible and promptly completed. At a minimum, facility
health records for each client must include written documentation of the
following:
(1) client demographics;
(2) client consent forms;
(3) pertinent medical, social, family,
reproductive and nutritional history;
(4) a list of medications that are currently
prescribed for the client, including any self-administered over-the-counter
medication or neutraceuticals, including dose of medication, route of
administration, and frequency of use;
(5) allergy list;
(6) initial physical exam;
(7) initial and on-going risk assessment and
status;
(8) laboratory, radiology
and other diagnostic reports;
(9)
assessment of the health status and health care needs of the client;
(10) evidence of continuous prenatal care
including progress notes;
(11)
evidence of prenatal educational resources;
(12) labor and birth summary;
(13) postpartum care with evidence of
follow-up within 48 hours of birth;
(14) newborn care and follow-up;
(15) appropriate referral of ineligible
clients and documentation of transfer of care;
(16) documentation of any consultations,
special examinations and procedures;
(17) discharge summary and applicable
instructions to the client;
(18)
list of staff present during labor, birth and postpartum;
(19) evidence that client rights have been
provided to each client; and
(20)
consent form for participation in research signed by the client, if
applicable.
B. Client
records maintenance:
(1) current client
records shall be maintained on-site and stored in an organized, accessible and
permanent manner, with copies easily accessible for review, transfers or in an
emergency;
(2) the facility shall
have in place policies and procedures in compliance with applicable law, for
maintaining and ensuring the confidentiality of client records, which include
the authorized release of information from the client records; and the
retention and transfer of client records at closure or ownership
changes;
(3) noncurrent client
records shall be maintained by the facility against loss, destruction and
unauthorized use for a period of not less than five years from the date of
discharge and be readily available within 24 hours of request; if, any other
applicable statutes or regulations require a longer term of record retention
than five years, the longer term shall apply to the facility.
C. Chart review: At a minimum, a
chart review performed by the internal quality committee shall consider written
documentation of:
(1) appropriateness of
admissions and continuation of services;
(2) complete client demographic
information;
(3) signed informed
consent(s);
(4) appropriate
referral of ineligible clients;
(5)
continuous prenatal visits, beginning no later than 32 weeks;
(6) continuous risk assessment throughout
prenatal care and for admission in labor;
(7) appropriate maternal and newborn
follow-up after birth;
(8)
appropriateness of diagnostic and screening procedures;
(9) complete initial history;
(10) complete initial physical
exam;
(11) complete prenatal labs
and screenings;
(12)
appropriateness of medications prescribed, dispensed or administered;
(13) documentation of medical consultation,
if indicated;
(14) appropriate
identification and management of complications;
(15) appropriate transfer of care for
maternal/fetal/newborn indications;
(16) compliance with these rules;
(17) compliance with policies, procedures and
clinical practice guidelines for maternal and fetal assessment during labor and
postpartum;
(18) compliance with
evidence based standards of practice;
(19) effectiveness of staff utilization and
training;
(20) completeness of
client records;
(21) review of the
management of care of individual clients or targeted types of clients or cases
for the appropriateness of the clinical judgment of the practitioner(s) in
obtaining consultation and managing the case relative to standards of care and
policies; and make recommendations for any improvements of care; and
(22) review and analyze outcome data and
trends, and client satisfaction survey results.
