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Section → I-E
To establish minimum standards in regard to RECORD KEEPING
The licensed midwife shall keep appropriate records on all clients.
All records shall, at a minimum:
- Be accurate, current and comprehensive, giving information concerning the condition and care of the client and associated observations
- Provide a record of any problems that arise and actions taken in response to them
- Provide evidence of care required, interventions provided by professional practitioners and patient responses
- Record factors–physical, psychological, or social– that appear to affect the patient
- Record the chronology of events and the reasons behind decisions made
- Provide baseline data against which improvement or deterioration may be judged
- Date each entry or page and include a signature or initials for each entry or page
- Make records available to the receiving health care provider in the event of transfer of care or the transport of mother or newborn
The licensed midwife:
- Facilitates clients’ access to their own records
- Complies with HIPPA regulations regarding confidentiality and notification of client prior to release of records to third parties
- Retains records for a minimum of seven years
- Completes/files all state required reports/certificates in a timely manner
Client records shall, at a minimum, include the following categories unless parents declined to have certain procedures:
- All pertinent forms for disclosure of information and informed consent, including any decline of care waivers, etc.
- Intake interview, medical and maternity history, physical exam/assessment, labs and other test results, risk-assessment and emergency plan
- Routine prenatal assessments, physical findings, interventions & recommendations
- Referrals and consultations with physicians or other health care providers and reports such as ultrasound, bio-physical profiles, AFP, etc
- Intrapartum records that include maternal assessments and progress during labor
- Fetal assessments during labor
- Administration of any drugs, including anti-haemorrhagic agents, IV fluids, and maternal Rhogam and neonatal eye prophylaxis and vitamin K
- Apgar scores and newborn examination
- Postpartum care/visits, and follow-up neonatal evaluations
- Information about newborn genetic screening
- Copies of birth registration forms