New York Codes, Rules and Regulations
Title 10 - DEPARTMENT OF HEALTH
Chapter V - Medical Facilities
Subchapter C - State Hospital Code
Article 6 - Treatment Center and Diagnostic Center Operation
Part 754 - Birth Center Services
Section 754.8 - Medical records

Universal Citation: 10 NY Comp Codes Rules and Regs ยง 754.8

Current through Register Vol. 46, No. 39, September 25, 2024

The operator shall ensure that, in addition to meeting the requirements in section 751.7 of this Title:

(a) The medical record for each woman admitted to the birth center shall contain the following information:

(1) results of physical and risk assessments;

(2) maternal history, to include medical, surgical, gynecological and psychosocial history;

(3) informed consent for birth center services;

(4) ongoing assessments of fetal growth and development;

(5) periodic evaluations of maternal health;

(6) results of laboratory tests;

(7) labor and birth information;

(8) newborn physical assessment, including APGAR scores, maternal-newborn interaction, ability to feed, eye prophylaxis, vital signs and accommodation to extrauterine life;

(9) postpartum assessment;

(10) discharge and follow-up plans;

(11) home visit reports;

(12) birth center follow-up visit report; and

(13) documentation of family planning counseling and the arrangements made for family planning services, if any.

(b) The medical record for each newborn shall be cross-referenced with the mother's medical record and contain the following information:

(1) copy of the newborn physical assessment;

(2) results from newborn screening tests;

(3) discharge summary with follow-up plans; and

(4) home visit report.

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