Section 795.8 - Medical records

Section 795.8 Medical records. The operator shall ensure that, in addition to meeting the requirements in section 751.7 of this Title:

(a) The medical record for each patient shall contain the following information:

(1) results of physical and risk assessments;

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

(3) record of informed consent, including shared decision making, for midwifery birth center services;

(4) ongoing assessments of fetal growth and development;

(5) periodic evaluations of patient health;

(6) results of laboratory tests;

(7) labor and birth information;

(8) newborn patient 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) midwifery 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 patient’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.

 

Effective Date: 
Wednesday, November 13, 2019
Statutory Authority: 
Public Health Law, Sections 2801 and 2803(11)