Okla. Admin. Code § 310:395-5-15

Current through Vol. 42, No. 7, December 16, 2024

Section 310:395-5-15 - Record keeping

(a) All Licensed Midwives shall keep accurate and complete physical or electronic records of all care provided and data gathered for each Client.

(b) The Licensed Midwife shall maintain an individual Client chart for each woman under his or her care. The chart shall include results of laboratory tests, observations from each prenatal visit, records of consultations with physicians or other health care providers, and a postpartum report concerning labor, delivery, and condition of the Newborn child. The chart shall be made available to the Client upon request, and with the Client's consent, to any physician or health care provider who is called in as a consultant or to assist in the Client's care. Inactive records shall be maintained no less than twenty-five (25) years (age of majority +7). All records are subject to review by the Department and shall be provided to the Department upon request.

(c) Licensed Midwives shall be responsible for complying with the applicable state and federal regulations in regard to the security, safety and confidentiality of any medical record they create, maintain, transfer, or destroy whether the record is written, taped, computerized, or stored in any other medium.

(d) Licensed Midwives shall provide the Client with a copy of the Client's record in accordance with state law. In situations involving multiple Clients, access to records is limited to those parts of records that do not include confidential information related to another Client.

Okla. Admin. Code § 310:395-5-15

Adopted by Oklahoma Register, Volume 38, Issue 06, December 1, 2020, eff. 11/2/2020

Adopted by Oklahoma Register, Volume 38, Issue 12, March 1, 2021, eff. 2/2/2021

Adopted by Oklahoma Register, Volume 38, Issue 24, September 1, 2021, eff. 9/11/2021