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Title: Section 754.8 - Medical records

754.8 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 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.


VOLUME E (Title 10)