Section 7 AAC 12.425 - Medical records(a) A birth center shall keep records for all clients admitted. Originals, or accurate reproductions of the contents of the originals, of all records, including x-rays, must be maintained in a form that is legible and uniform, contains complete and accurate client and newborn information, and fully describes continuity of care. The birth center shall ensure that these records are readily available upon the request of the physician, consulting physician, midwife, or the department or, upon the client's written request, to other practitioners. The birth center shall maintain each record in a system that protects confidentiality of the information contained in its records, that provides for proper storage, easy retrieval, and prevention of loss, and that protects against the use or disclosure of protected health information except as required or permitted by 45 C.F.R. Part 160, subpart C, and 45 C.F.R. Part 164, subpart E, adopted by reference in 7 AAC 12.770(d). The birth center shall develop, for use by the clinical staff, a form for providing information necessary for a transfer of a client or newborn to a hospital. The birth center shall ensure that a copy of the prenatal record is available before and during labor. The birth center shall ensure that a copy of the complete record for a client or newborn is provided at the time of any transfer or referral.(b) Each medical record must include (1) an identification sheet that includes (A) the client's (ii) medical record number;(iii) address on admission;(B) the date of admission;(C) the name, address, and telephone number of a contact person;(D) proof that the birth center provided the client a complete orientation in accordance with 7 AAC 12.403(d);(E) a plan for payment for services;(F) the client's social, family, medical, reproductive, nutritional, and behavioral history;(G) the results of an initial physical examination;(H) the results of a risk assessment conducted upon admission in accordance with the standards developed under 7 AAC 12.403(f);(I) evidence of appropriate referral for an ineligible client, including the report completed during initial screening;(J) the results of continuous periodic prenatal examination, including evaluation of risk factors and risk status in accordance with the standards developed under 7 AAC 12.403(f); and(K) information regarding instruction and education provided, including nutritional counseling, changes in pregnancy, self-care in pregnancy, orientation to health records, understanding of findings on examinations and laboratory tests, preparation for labor, sibling preparation, and newborn assessment and care;(2) an order sheet that includes medication and treatment, signed by a midwife or another practitioner who ordered the medication or treatment;(3) notes entered by the clinical staff, including(A) an accurate record of care given;(B) a record of pertinent observations and responses to treatment of the client including psychosocial and physical manifestations;(C) an assessment at the time of admission;(E) the name, dosage, and time of administration of a medication or treatment, the route of administration and site of injection of a medication if other than by oral administration, the client's or newborn's response, and the signature of the person who administered the medication or treatment;(F) documentation that initial bloodspot screening was completed for the newborn;(G) documentation on admission of the client's vital signs, including temperature, pulse, respiration, and blood pressure;(H) documentation of the client's vital signs at least every four hours during the latent phase of labor;(I) documentation of any change in vital signs in the presence of risk factors, including rupture of membranes and borderline blood pressure;(J) documentation on admission of uterine contractions;(K) documentation of fetal heart tones on admission and periodically during the latent phase of labor;(L) documentation of fetal heart tones at least every 30 minutes during the active phase of labor;(M) documentation of fetal heart tones at least every 5 to 15 minutes when pushing is occurring;(N) documentation of fetal heart tones after rupture of membranes;(O) documentation of the client's vital signs within the first hour after delivery;(P) documentation of the newborn's vital signs, including tone color, within the first hour after delivery; and(Q) documentation of at least one additional set of client and newborn vital signs before discharge from the birth center;(4) treatments, consultations, and laboratory reports;(5) informed consent forms signed by the client and midwife;(6) monitoring of progress in labor with ongoing assessment of client and fetal reaction to the process of labor;(8) the record of a neonatal physical examination, including Apgar scores, client and newborn interaction, prophylactic procedures, accommodation of the newborn to extrauterine life, and blood glucose if clinically indicated;(9) any consultation regarding referral and transfer for any client or neonatal problem that elevates risk status under the standards developed under 7 AAC 12.403(f);(10) evidence of screening for gram positive Group B Streptococcusby an approved laboratory, Group B Streptococcustreatment as necessary, information provided to the client regarding Group B Streptococcus, and monitoring after delivery of each newborn born to a client who tests positive for Group B Streptococcusor to a client with unknown status;(11) ongoing physical assessment of the client and newborn during recovery;(12) a summary of the progress of labor;(13) a discharge summary for the client and the newborn;(14) a plan for newborn health supervision, completion of the initial bloodspot screening, and required follow-up screening, including the provision for newborn hearing screening; and(15) follow-up postpartum evaluation of the client, counseling for family planning, and other services.(c) The birth center shall maintain procedures to protect the information in medical records from loss, defacement, tampering, or access by unauthorized persons.(d) The birth center shall index and file records using a uniform system that allows for efficient retrieval according to a single identifying number for each client.(e) A transfer summary, signed by the midwife or collaborating physician, must accompany the client or newborn if the client or newborn is transferred to a hospital. The transfer summary must include essential information regarding the client's or newborn's diagnosis, condition, medications, treatments, dietary requirements, known allergies, and treatment plan.(f) The birth center shall establish and maintain a system for periodic review of the birth center's record-keeping system and its policies and procedures for the maintenance, storage, retrieval, and retirement of client and newborn records.(g) The birth center shall appoint an individual who is a member of the clinical or support staff to be responsible for the processing, maintenance, and storage of records, and who will ensure that access to records is limited to persons authorized to review those records.(h) The birth center shall retain and preserve records that relate directly to the care and treatment of a client or newborn for at least seven years after discharge. However, the records of a client who is under 19 years of age must be kept until at least two years after the client has reached 19 years of age or until seven years after discharge, whichever is longer. The birth center shall retain and preserve records consisting of x-ray film for at least five years.Eff. 5/14/82, Register 82; am 11/19/83, Register 88; am 9/30/2007, Register 183; am 7/1/2018,Register 226, July 2018Authority:AS 47.32.010
AS 47.32.030
AS 47.32.100
AS 47.32.110