Oklahoma Administrative Code
Title 310 - Oklahoma State Department of Health
Chapter 616 - Birthing Centers Regulations
Subchapter 3 - Administration
Section 310:616-3-3 - Reports and records
Universal Citation: OK Admin Code 310:616-3-3
Current through Vol. 41, No. 13, March 15, 2024
(a) Reports. Reports shall be made by the birthing center to the appropriate agency, including but not limited to the following:
(1) Communicable diseases.
(2) Births and deaths.
(3) Periodic reports to the Department on
forms supplied for this purpose.
(4) Newborn hearing screening
report.
(5) Newborn metabolic
screening.
(6) Birth
defects.
(b) Retention and preservation of records.
(1)
State retention
requirements. Medical records will be retained a minimum of five years
beyond the date the patient was last seen or a minimum of three years beyond
the date of the patient's death.
(2)
Preservation of records.
Birthing centers generating medical records may microfilm the medical records
and destroy the original record in order to conserve space.
(c) Record of care.
(1) The birthing center shall establish and
maintain a medical record for each mother and infant receiving care and
services. The record shall be complete, timely and accurately documented, and
readily accessible.
(2) The medical
record shall contain sufficient information to justify the diagnosis and
treatment and warrant the services provided. Entries are made and signed by the
person providing the services. The record shall include all care and services
whether furnished directly or under arrangement made by the center. Each record
shall contain at least, but not limited to, the following:
(A) Identification data.
(B) Initial and subsequent
assessments.
(C) Record of prenatal
care.
(D) Medical history and
physical exam.
(E) Risk
assessment.
(F) Allergies and
medication reactions.
(G) A
disclosure statement signed by the patient explaining the principles of
midwifery, benefits, limitations, and risks available to them at the birthing
center and describing the arrangements the center has with physicians and the
referral hospitals.
(H) Plan of
care.
(I) Laboratory
reports.
(J) X-Ray
reports.
(K) Intrapartum
care.
(L) Postpartum
care.
(M) Newborn care.
(N) Patient's compliance to advice and/or
treatment.
(O) Discharge
Summary.
Added at 9 Ok Reg 1715, eff 4-13-92 (emergency); Added at 9 Ok Reg 1979, eff 6-11-92
Disclaimer: These regulations may not be the most recent version. Oklahoma 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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