Section R432-550-20 - Medical Records(1) Medical records shall be complete, accurately documented and systematically organized to facilitate retrieval and compilation of information.(2) An employee designated by the administrator shall be responsible and accountable for the processing of medical records.(3) The medical record and its contents shall be safeguarded from loss, defacement, tampering, fires and floods.(4) Medical records shall be protected against access by unauthorized individuals. Birthing centers shall: (a) keep medical record information confidential; and(b) obtain consent from the patient before releasing client information identifying the client, including photographs, unless release is otherwise allowed or required by law. (5) Medical records shall be retained for at least five years after the last date of patient care. Records of minors, including records of newborn infants, shall be retained for three years after the minor reaches legal age under Utah law, but in no case less than five years.(6) The birthing center shall maintain an individual medical record for each patient which shall include but is not limited to written documentation of the following: (a) admission record with demographic information and patient identification data;(b) history and physical examination which shall be up-to-date upon the patient's admission;(c) written and signed informed consent;(d) orders by a clinical staff member;(e) record of assessments, plan of care and services provided;(f) record of medications and treatments administered;(g) laboratory and radiology reports;(h) discharge summary for mother and newborn to include a note of condition, instructions given and referral as appropriate;(i) prenatal care record containing at least prenatal blood serology, Rh factor determination, past obstetrical history and physical examination and documentation of fetal status;(j) monitoring of progress in labor with assessment of maternal and newborn reaction to the process of labor;(k) fetal monitoring record;(l) labor and delivery record, including type of delivery, record of anesthesia and operative procedures if any; and(m) documentation that the patient is informed of the statement of patient rights.(7) The records of newborn infants shall include the following:(a) date and hour of birth, birth weight and length, period of gestation, gender and condition of infant on delivery including Apgar scores and resuscitative measures;(b) mother's name or unique identification;(c) record of ophthalmic prophylaxis; and(d) the identification number of the screening kit used to screen for metabolic diseases, documentation that metabolic screening, genetic screening, PKU or other metabolic disorders reports were completed or refused by the client.(8) An alongside midwifery unit may integrate medical records with the medical record system of the adjoining hospital.Utah Admin. Code R432-550-20
Amended by Utah State Bulletin Number 2016-11, effective 5/16/2016Amended by Utah State Bulletin Number 2016-18, effective 8/26/2016Amended by Utah State Bulletin Number 2021-07, effective 3/10/2021