Current through Register Vol. 24-18, September 15, 2024
The purpose of this section is to assure the center obtains,
manages, and uses information to improve patient outcomes and the performance
of the birth center in patient care.
(1) The birth center shall have a defined
client record system, policies and procedures which provide for identification,
security, confidentiality, control, retrieval, and preservation of client care
data and information.
(2) The
childbirth center must maintain a health record for each maternal and newborn
client in a legally acceptable, integrated and chronological document on the
licensee's standardized forms consistent with chapter 70.02 RCW, Medical
records -- Health care information access and disclosure. Each record must
include:
(a) Client's demographic information
and client identification to include at a minimum client's name, birth date,
age, and address;
(b) Client's
informed consent for care, service, treatment and receipt of the client bill of
rights;
(c) Signed and
authenticated notes describing the newborn and maternal status during prenatal,
labor, birth, and recovery including, but not limited to:
(i) Documentation that verifies the client's
low-risk maternal client status; and
(ii) Labor summary;
(iii) Newborn status including Apgar scores,
maternal newborn interaction; and
(iv) Physical assessment of the mother and
newborn during recovery;
(d) Documentation that a newborn screening
specimen was collected (or signed refusal on the back of the specimen form) and
submitted to the department's newborn screening program under WAC
246-650-020;
(e) Documentation and authentication of
orders by clinical staff and birth center personnel who administer drugs and
treatments or make observations and assessments;
(f) Laboratory and diagnostic testing
results;
(g) Consultation
reports;
(h) Referral, transfer of
care, emergency transfer and transport documentation;
(i) Prophylactic treatment of the eyes of the
newborn in accordance with WAC
246-100-206(6)(b);
(j) Prenatal screening under chapters 70.54
RCW and 246-680 WAC, including client's refusal;
(k) Documentation of refusal of rapid HIV
testing if documentation of an HIV test during prenatal care is not
available;
(l) For HIV positive
women, the antiretroviral medications during delivery and recommended lab
tests;
(m) Intrapartum antibiotics
for Group B Strep positive women per the CDC protocol;
(n) For Hepatitis B positive women, HBIG and
Hepatitis B immunization for newborn;
(o) Refusal of any recommended test or
treatment;
(p) Documentation of
birth registration per chapter 70.58 RCW.
(3) For clients managed by a contractor in a
birth center, the licensee shall ensure that each client record is maintained
by the birth center and must contain the information as stated in subsection
(2)(a) through (p) of this section. Services provided by the contractor, prior
to the client's admission to the birth center, shall be summarized or placed in
the record in their entirety.
(4)
Entries in the client record shall be typewritten, retrievable by electronic
means or written legibly in ink.
(5) Documentation and record keeping shall
include:
(a) Completion of a birth
certificate and, if applicable, a sentinel birth defect report under chapters
70.58 RCW and 246-491 WAC.
(b)
Documentation of orders for medical treatment and/or medication. Each order
shall be specific to the client and shall be authenticated, at the time the
order is received, by an appropriate health care professional authorized to
approve the order or medication.
(6) The licensee shall:
(a) Assure client records are kept
confidential;
(b) Fasten client
records together;
(c) Consider
client records property of the birth center; and
(d) Provide a client access to their client
record under the licensee's policy and procedure and applicable
rules.
(7) When a client
is transferred or discharged to another provider or facility, the birth center
must provide a summary of care to the provider or facility to whom the client
is transferred or discharged.
(8)
The licensee shall maintain records for:
(a)
Adults - three years following the date of termination of services;
and
(b) Minors - three years after
attaining age eighteen, or five years following discharge, whichever is
longer.
(9) The licensee
shall:
(a) Store records to prevent loss of
information and to maintain the integrity of the record and protect against
unauthorized use;
(b) Maintain or
release records after a patient's or client's death according to chapter 70.02
RCW, Medical records -- Health care information access and disclosure;
and
(c) After ceasing operation,
retain or dispose of records in a confidential manner according to the time
frames in this subsection.
Statutory Authority: Chapter 18.46 RCW and RCW 43.70.040.
07-07-075, § 246-329-140, filed 3/16/07, effective
4/16/07.
