Oklahoma Administrative Code
Title 310 - Oklahoma State Department of Health
Chapter 667 - Hospital Standards
Subchapter 19 - Medical Records Department
Section 310:667-19-2 - Reports and records
Universal Citation: OK Admin Code 310:667-19-2
Current through Vol. 41, No. 13, March 15, 2024
(a) Reports shall be made by each hospital to the appropriate agency, including but not limited to the following:
(1) Communicable
disease.
(2) Births and
deaths.
(3) Periodic reports to the
Department on forms supplied for this purpose.
(4) Newborn hearing screening report.
(A) All hospital nurseries shall complete a
newborn hearing screening report form on all live newborns discharged from
their facility. For facilities with a two-year average annual birth census of
fifteen (15) or greater, physiologic hearing screening results as well as "at
risk" indicators must be recorded on the report form; for facilities with a
two-year average annual birth census of fewer than fifteen (15), "at risk"
indicators must be recorded and if physiologic hearing screening is conducted,
those results also must be recorded on the report form. It shall be the
responsibility of the hospital administrator to assure that the Newborn Hearing
Screening Report Form is correctly completed and subsequently submitted to the
Department. The hospital administrator may designate one individual, who shall
then be responsible for review of all newborn discharge summaries to insure
that a report form has been completed for each infant and that the report form
is a permanent part of that infant's record. A copy of the hearing screening
report form must be given to the infant's caregiver at discharge.
(B) If an infant is transferred from one
hospital to another, the second hospital shall be responsible for providing
physiologic hearing screening, "risk indicator" screening, and for completion
of the report form.
(C) It shall be
the responsibility of the hospital administrator to insure that all completed
report forms are mailed to the Department within seven (7) days of an infant's
birth.
(D) It shall be the
responsibility of the attending physician or licensed independent practitioner
to inform parents if their infant passed or was referred on the physiologic
hearing screening and/or if the infant is to be considered "at risk" for
hearing impairment. Prior to discharge, the attending physician or licensed
independent practitioner shall review the completed report form and shall
inform the parents of their infant's status. Infants who do not pass the
physiologic screening shall be referred for a diagnostic audiological
evaluation as soon as possible.
(E)
It shall be the responsibility of the coordinator of the Newborn Hearing
Screening Program at the Department to arrange for hospital in-service training
for all hospital personnel involved in the process of completion of report
forms. A manual of procedures shall be available in regard to processing of
screening forms. The literature for distribution to parents shall be available
from the Department.
(5)
Newborn metabolic disorder screening.
(A)
Testing of newborns. All newborns in Oklahoma shall be tested for
phenylketonuria, hypothyroidism, galactosemia and sickle cell diseases, cystic
fibrosis, congenital adrenal hyperplasia, medium-chain acyl coenzyme A
dehydrogenase deficiency (MCAD), biotinidase deficiency, amino acid disorders,
fatty acid oxidation disorders, organic acid disorders, severe combined
immunodeficiency (SCID), spinal muscular atrophy (SMA), x-linked
adrenoleukodystrophy (X-ALD), mucopolysaccharidoisis type I (MPS I) and Pompe
disease upon completion of laboratory validation studies, establishment of
short-term follow-up services, and approval by the Commissioner of Health as
defined in Chapter 550 of this Title. All infants born at a birthing facility
in Oklahoma shall be screened for Critical Congenital Heart Disease (CCHD)
utilizing pulse oximetry. A parent or guardian may refuse newborn screening
and/or pulse oximetry screening of their newborn on the grounds that such
examination conflicts with their religious tenets and/or practices. A parent or
guardian who refuses newborn screening or pulse oximetry screening of their
newborn on the grounds that such examination conflicts with their religious
tenets and/or practices shall also indicate in writing this refusal in the
newborn's medical record with a copy sent to the Newborn Screening Program,
Oklahoma State Department of Health, 1000 NE Tenth Street, Oklahoma City,
Oklahoma 73117-1299.
(B)
Specimen collection for hospital births. For all live hospital
births, the physician or licensed independent practitioner shall order the
collection of a newborn screening specimen prior to transfusion, as early as
possible after twenty-four (24) hours of age or immediately prior to discharge,
whichever comes first. Specimens shall be collected on the Newborn Screening
Form Kit using capillary or venous blood. Cord blood is unacceptable. The
hospital is responsible for collecting specimens on all infants.
(i) If the initial specimen for any infant is
collected at or prior to twenty-four (24) hours of age, the hospital and the
physician or licensed independent practitioner are responsible for notifying
the infant's parents that a repeat specimen is necessary at three to five days
of age. The infant's physician or licensed independent practitioner is
responsible for ensuring that the repeat specimen is collected.
(ii) The hospital is responsible for
submitting a satisfactory specimen and for documenting all requested
information on the form kit including the parent/guardian's name, address,
phone or contact phone number and the planned health care provider who will be
providing well care for the infant after discharge. Or if the infant is to be
hospitalized for an extended period of time, the name of the infant's physician
or licensed independent practitioner.
(iii) The hospital is responsible for
documenting specimen collection and results in the infant's hospital
record.
(iv) Infants transferred
from one hospital to another during the newborn period shall have specimen
collection documented in the infant's hospital record. It is the responsibility
of the physician or licensed independent practitioner and the receiving
hospital to insure a specimen is collected.
(v) It is the responsibility of the hospital
and physician or licensed independent practitioner to ensure that all infants
are screened prior to discharge. If an infant is discharged prior to specimen
collection, the Newborn Screening Program Coordinator shall be notified by
contacting Newborn Screening Program,, Oklahoma State Department of Health,
1000 NE Tenth Street, Oklahoma City, Oklahoma 73117-1299, (405) 271-6617, FAX
(405) 271-4892, 1-800-766-2223, ext. 6617. The physician or licensed
independent practitioner is responsible for ensuring the specimen is collected
as early as possible after twenty-four (24) hours of age.
(C)
Pulse oximetry screening for
birthing hospitals. For all live hospital births, the physician or
licensed independent practitioner shall order the pulse oximetry screening for
newborns to be performed after twenty-four (24) hours of age or prior to
discharge from a facility.
(i) If unable to
perform the screening after twenty-four (24) hours of age or prior to
discharge, schedule the infant to be screened at the hospital between
twenty-four (24) hours and forty-eight (48) hours of life; or notify the
infant's physician if screening was not performed.
(ii) If the newborn infant is discharged from
a facility after twelve (12) hours of life but before twenty-four (24) hours of
life, the birthing facility shall perform screening as late as is practical
before the newborn infant is discharged from the birthing facility.
(iii) If the infant is discharged before
twelve (12) hours of life, the birthing facility shall perform the screening
between twenty-four (24) hours and forty-eight (48) hours of life.
(iv) For newborn infants in special care or
intensive care, birthing facilities shall perform pulse oximetry screen on
infants prior to discharge utilizing recommended protocol, unless the infant
has an identified congenital heart defect or has an echocardiogram performed.
Continuous pulse oximetry monitoring may not be substituted for CCHD
screening.
(v) There may be
instances where screening for CCHD is not indicated, including but not limited
to instances where:
(I) The newborn infant's
clinical evaluation to date has included an echocardiogram which ruled out
CCHD; or
(II) The newborn infant
has confirmed CCHD based on prenatal or postnatal testing.
(III) Indicate on NBS filter paper that
screening was not performed.
(D)
Screening for premature/sick
infants. For all premature/sick infants, the physician or licensed
independent practitioner shall order the collection of a newborn screening
specimen prior to red blood cell transfusion, as early as possible after 24
hours of age but no later than three to seven days of age, or immediately prior
to discharge, whichever comes first. Due to the need to identify infants at
risk for the disorders quickly, the specimen should be collected as early as
possible after twenty-four (24) hours of age. It is recommended that a repeat
newborn screening specimen be collected at fourteen (14) days of age. Specimens
shall be collected on the Newborn Screening Form Kit using capillary or venous
blood. The hospital is responsible for collecting specimens on all
premature/sick infants.
(i) Premature/sick
infants screened prior to twenty-four (24) hours of age must be re-screened
between seven to fourteen (7-14) days of age.
(ii) Premature/sick infants who could not be
screened prior to a red blood cell transfusion should be re-screened by the
seventh (7
th ) day of life and a repeat specimen
collected when plasma and/or red cells will again reflect the infant's own
metabolic processes or phenotype. The accepted time period to determine
hemoglobin type is ninety to one hundred and twenty (90 to 120) days after
transfusion.
(iii) The recommended
follow-up study for an abnormal thyroid screen in a premature infant is a serum
free T4 (measured by direct dialysis or an equivalent method) and TSH at seven
to fourteen (7-14) days of age.
(E)
Newborn Screening Hospital
recording. The hospital shall implement a procedure to assure that a
newborn screening specimen has been collected on every newborn and mailed to
the Newborn Screening Laboratory within twenty four to forty-eight (24 - 48)
hours of collection.
(i) The hospital shall
immediately notify the infant's physician or licensed independent practitioner,
and parents or guardians if an infant is discharged without a sample having
been collected. This notification shall be documented in the infant's hospital
record.
(ii) If no test results are
received within fifteen (15) days after the date of collection, the hospital
shall contact the Newborn Screening Laboratory to verify that a specimen had
been received. If no specimen has been received, the hospital shall notify the
physician or licensed independent practitioner.
(iii) Any hospital or any other laboratory
which collects, handles or forwards newborn screening samples shall keep a log
containing name and date of birth of the infant, name of the attending
physician or licensed independent practitioner, name of the health care
provider who will be providing well care for the infant after discharge,
medical record number, serial number of the form kit used, date the specimen
was drawn, date the specimen was forwarded, date the test results were received
and the test results, and pulse oximetry screening results.
(F)
Pulse oximetry screening
hospital recording. The hospital shall implement a procedure to assure
that pulse oximetry screening has been performed on every newborn prior to
discharge.
(i) All pulse oximetry screening
results shall be recorded in the newborn infant's medical record and results
reported to a parent or guardian prior to discharge from the
hospital.
(ii) All pulse oximetry
screening results shall be recorded on the Newborn Screening Form Kit, or faxed
to the Oklahoma State Department of Health Newborn Screening Program.
(G)
Parent and health care
provider education. The hospital will be responsible or designate a
responsible party to distribute the Newborn Screening Program's written
educational materials on newborn screening and pulse oximetry screening
provided by the Department to at least one of each newborn's parent or legal
guardian.
(H)
Training. Hospitals shall provide ongoing training programs for
their employees involved with newborn screening procedures. These training
programs shall include methods of collecting a satisfactory newborn screening
specimen and proper pulse oximetry screening methods. The hospital is
responsible for ensuring that employees who collect, handle or perform newborn
screening tests; or perform pulse oximetry screening are informed of their
responsibilities with respect to screening procedures.
(6)
Birth defects. Each hospital
shall maintain a list of patients up to six (6) years of age who have been
diagnosed with birth defects, and all women discharged with a diagnosis of
stillbirth or miscarriage. On request, each hospital shall make the medical
records of these individuals available to the State Department of
Health.
(7)
Abortions.
Attending physicians shall complete and submit to the Department a report form
for each abortion performed or induced as required by 63 O.S. 1999, Section
1-738.
(b) Record of patient admission.
(1) All persons
admitted to any institution covered by these standards shall be under the care
of a doctor of medicine (M.D.) or osteopathy (D.O.) duly licensed to practice
medicine and surgery in the State of Oklahoma or a licensed independent
practitioner, whose name shall be shown on the admitting record.
(2) The hospital admitting record also shall
show the following for each patient.
(A) Full
name of patient with age, sex, address, marital status, birth date, home phone
number, date of admission, and admitting diagnosis.
(B) Next of kin, with address, phone number,
and relationship.
(C) Date and time
of admission, the admission and final diagnoses, and the name of physician or
licensed independent practitioner.
(D) Any advanced directive for health care as
defined in the Oklahoma Rights of the Terminally Ill or Persistently
Unconscious Act.
(3)
Special clinical reports shall be kept, including the following:
(A) Obstetrical patients throughout labor,
delivery, and post-partum.
(B)
Newborn, giving the infant's weight, length, and other notes relative to
physical examination.
(C) Surgical
and operative procedures, including pathological reports.
(D) Record of anesthesia
administration.
(c) Orders for medications, treatments, and tests.
(1) All medication orders
shall be written in ink and signed by the ordering physician or practitioner
authorized by law to order the medication, with the exception of influenza and
pneumococcal polysaccharide vaccines, which may be administered per physician-
approved hospital policy after an assessment for contraindications. The order
shall be preserved on the patient's chart.
(2) All orders shall be written in ink and
signed by the ordering physician or practitioner. Orders received by resident
physicians shall be co-signed if required by medical staff bylaws. The order
shall be preserved on the patient's chart.
(3) All orders taken from the physician or
practitioner, for entry by persons other than the physician or practitioner,
shall be countersigned.
(4)
Telephone or verbal orders may be authenticated by an authorized physician or
practitioner other than the ordering physician or practitioner when this
practice is defined and approved in the medical staff bylaws. If allowed,
medical staff bylaws must identify the physicians or practitioners who may
authenticate another physician's or practitioner's telephone or verbal order,
e.g. physician partners or attending physicians or practitioners, and define
the circumstances under which this practice is allowed. The bylaws must also
specify that when a covering or attending physician or practitioner
authenticates the ordering physician's or practitioner's telephone or verbal
order, such an authentication indicates that the covering or attending
physician or practitioner assumes responsibility for his or her colleague's
order and verifies the order is complete, accurate, appropriate, and final. The
person taking the telephone or verbal order shall read the order back to the
physician or practitioner to ensure it was correctly understood and verify on
the order the fact that the order was read back. Each facility, within its own
procedures and protocols, shall establish a verification process to be placed
on orders to demonstrate that the order was read back to the
physician.
Added at 12 Ok Reg 1555, eff 4-12-95 (emergency); Added at 12 Ok Reg 2429, eff 6-26-95; Amended at 18 Ok Reg 2032, eff 6-11-01; Amended at 20 Ok Reg 1664, eff 6-12-03; Amended at 24 Ok Reg 1189, eff 4-2-07 (emergency); Amended at 25 Ok Reg 2472, eff 7-11-08; Amended at 30 Ok Reg 1966, eff 7-25-13
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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