CCM edit: Sec. I-E Record Keeping – Rosanna G. Doc

 New Page and New Section

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:

1. Be accurate, current and comprehensive, giving information concerning the condition and care of the client and associated observations

2. Provide a record of any problems that arise and actions taken in response to them
3. Provide evidence of care required, interventions provided by professional practitioners and patient responses

4. Record factors–physical, psychological, or social– that appear to affect the patient
5. Record the chronology of events and the reasons behind decisions made
6. Provide baseline data against which improvement or deterioration may be judged
7. Date each entry or page and include a signature or initials for each entry or page
8. 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:

1. Facilitates clients’ access to their own records
2. Complies with HIPPA regulations regarding confidentiality and notification of client prior to release of records to third parties

3. Retains records for a minimum of seven years
4. 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:

1. All pertinent forms for disclosure of information and informed consent, including any decline of care waivers, etc.

2. Intake interview, medical and maternity history, physical exam/assessment, labs and other test results, risk-assessment and emergency plan

3. Routine prenatal assessments, physical findings, interventions & recommendations
4. Referrals and consultations with physicians or other health care providers and reports such as ultrasound, bio-physical profiles, AFP, etc

5. Intrapartum records that include maternal assessments and progress during labor
6. Fetal assessments during labor
7. Administration of any drugs, including anti-haemorrhagic agents, IV fluids, and maternal Rhogam and neonatal eye prophylaxis and vitamin K
8. Apgar scores and newborn examination
9. Postpartum care/visits, and follow-up neonatal evaluations
10. Information about newborn genetic screening
11. Copies of birth registration forms