N.H. Admin. Code § Mid 407.03

Current through Register No. 45, November 7, 2024

Section Mid 407.03 - Record of Client Care

(a) A midwife shall establish and maintain a record of the care provided and the data gathered for each client and newborn.

(b) Each client's record shall contain the following information, as applicable:

(1) The client's identification information including:

a. Name;

b. Address;

c. Telephone number;

d. Date of birth;

e. Marital status;

f. Name of spouse or partner, if any; and

g. Emergency contact person;

(2) The client's health history;

(3) Notes documenting the midwife's actions and guidance during personal and telephone contacts between:

a. The client and the midwife; and

b. The client's spouse or partner and the midwife;

(4) The dates and findings of:

a. Prenatal care given pursuant to Mid 502.03(a); and

b. Extended postpartum care given pursuant to Mid 502.07;

(5) Results of consultations with physicians or other health care providers;

(6) Laboratory and diagnostic reports;

(7) Documentation of all medications administered to the client;

(8) The signed originals of all forms required by these rules or other law to be signed by the client;

(9) The name and phone number of the health care provider chosen by the client to care for the newborn;

(10) Contemporaneously recorded details of the labor, the birth and the immediate postpartum period, annotated with the date and time for each entry;

(11) The midwife's written summary of the most important facts of the labor, the birth, and the assessment of the newborn; and

(12) The reasons for any transfer of the client's care.

(c) A midwife shall, with the written consent of the client, provide the newborn's health care provider with a copy of the summary required by (b)(11) above.

(d) A midwife shall retain each client's records for the longer of the following:

(1) A period of 21 years from the date of birth of a baby born while the client was in the care of the midwife; or

(2) A period of 7 years from the date of the midwife's last contact with the client if no baby was born while the client was in the care of the midwife.

N.H. Admin. Code § Mid 407.03

#8840, eff 3-13-07

Amended by Volume XXXVI Number 49, Filed December 8, 2016, Proposed by #12040, Effective 11/10/2016, Expires 11/10/2026.