Section 11-93-62 - Medical records(a) There shall be available sufficient appropriately qualified staff and necessary supporting personnel to facilitate the accurate processing, checking, indexing, filing and prompt retrieval of records and record data.(b) All patient records shall be confidential and are the property of the facility which shall secure them against loss, destruction, defacement, tampering, and use by legally unauthorized persons.(c) Patient records shall contain the following: (1) Prior to delivery, the patient record shall contain the following: (A) Sufficient history, physical examination, x-ray, and laboratory data to support the decision to utilize the birthing facility. The laboratory data must include an Rh factor determination, as well as the result of a serological test for syphilis.(B) Evidence of a search for any special hazards which might confront the patient and evidence of preparation to handle same should they develop.(C) An informed consent form signed by the patient or her guardian.(2) During and after delivery the patient record shall contain: (A) A record of all medications including administration of Rh immune globulin, obstetrical and anesthetic techniques used, as well as any surgical procedures.(B) Record of vital signs monitoring during all stages of delivery.(C) The condition and description of the placenta.(D) Condition of the mother and child at the time of discharge or transfer.(3) The medical record shall be kept current at all times so that in the event of transfer to another facility no time will be lost bringing records up-to-date.(d) Newborn records shall include the following: (1) Date and hour of birth; birth weight and length; period of gestation; sex; and condition of infant on delivery. An Apgar score shall be required.(2) Mother's name, Social Security number, and facility case number.(3) Record of opthalmic prophylaxis.(4) Record of any resuscitative procedures used.(5) Record of Vitamin K administration, and any other medication which were administered.(6) Appropriate physical examination at birth and at time of discharge.(7) Record of phenylketonuria, thyroid screening test, and other lab results.(e) A daily log with monthly summaries of all procedures performed in the facility and disposition of the patients shall be kept by the facility.[Eff. MAR 3, 1986] (Auth: HRS §§ 321-9, 321-10) (Imp: HRS §§ 321-10, 353-1, 622-57)