1. (1) Medical Records to be Kept. A birthing center shall keep comprehensive, organized, and readily accessible records for each patient (mother and newborn), including, but not limited to, admission and discharge notes, histories, physical examinations, nurses notes, procedure schedules, anesthesia/analgesic records, informed consent, follow-up care, and records of tests performed. The patients' records shall be current and kept with sufficient detail, consistent with good medical and professional practice, based on the services provided to each patient.
2. (2) Authentication of Records. All records shall be written, dated, and signed in an indelible manner, with the identity of the writer indicated, and made part of the patient's permanent record.
3. (3) Indexes. All health records should be indexed according to the patient's name.
4. (4) Facilities. A room or area shall be designated for maintaining paper copies of patient health records within the birthing center if a paper record is prepared. The area shall be sufficiently large and adequately equipped to permit the proper processing and storing of records and to protect them from fire or water damage. Access to electronic health records shall be properly secured and restricted to the birthing center's medical staff. All health records must be easily retrievable and readily accessible to the medical staff.
5. (5) Ownership. Health records shall be property of the facility and must be protected against loss, destruction, and unauthorized use; responsibility for the control of all such records shall rest with the administrator and the governing authority.
6. (6) Preservation of Records. Health records shall be preserved either in the original form, by microfilm, or in electronic form for a period of not less than 6 years following the most recent discharge of the patient. In the case of a minor, records shall be kept for 6 years after obtaining legal age. Mother and newborn records shall be kept together.

7. (7) Records are Confidential. Records and information regarding patients shall be confidential; however, patients may access and request copies of their own and their newborn's medical records, consistent with the provisions of HIPAA. The clinical record shall not be released without the written consent of the patient except under the following conditions:

   1. (a) When the patient is transferred to another source of care. A complete patient record shall accompany the mother or newborn in the event of an emergent or non-emergent transfer of care.
   2. (b) For audit by the Department during licensure inspection.
   3. (c) In response to a lawfully issued subpoena or court order.
   4. (d) As otherwise provided or required by HIPAA or other applicable state of federal law.

8. (8) Individual Patient Records. Each patient's health record shall include, but is not limited to, at least the following information:

   1. (a) Demographic information and patient identification.
   2. (b) Orientation to program and informed consent.
   3. (c) Complete social, family, medical, reproductive, nutrition, and behavioral history.
   4. (d) Initial physical examination, laboratory tests, and evaluation of risk status.
   5. (e) Appropriate referral of at risk patients with report of findings on risk assessment.
   6. (f) Development of a plan for care.
   7. (g) Continuous periodic prenatal examination and evaluation of risk factors including documentation of prenatal care provided outside the center at related practitioner or clinic sites.
   8. (h) Instruction and education including nutritional counseling, changes in pregnancy, self-care in pregnancy, orientation to health record and understanding of findings on examinations and laboratory tests, preparation for labor, sibling preparation, preparation for early discharge, newborn assessment and care, and feeding and medical evaluation.
   9. (i) History, physical examination, and risk assessment on admission to the birthing center in labor (labor graph).
   10. (j) Ongoing assessment of maternal and fetal status after admission to care and during the intrapartum period.
   11. (k) Evaluation of progress in labor with ongoing assessment of maternal and newborn reaction to the process of labor.
   12. (l) Consultation, referral, and transfer for maternal or neonatal problems that elevate risk status.
   13. (m) Physical assessment of newborn, including apgar scores, gestational age, maternal newborn interaction, feeding, prophylactic procedures, postpartum monitoring of vital signs, and accommodation to extrauterine life. The birthing center must perform an ongoing postpartum assessment of both mother and newborn.
   14. (n) Labor summary.
   15. (o) Discharge summary for mother and newborn.
   16. (p) Plan for newborn health supervision and required screening tests.
   17. (q) Plan for newborn health supervision and required screening tests.
   18. (r) Late postpartum evaluation of mother, counseling for family planning and other services, and evaluation of mother-child relationships.
   19. (s) Eye care, vitamin K.
   20. (t) All entries shall be dated and signed by the attending professional staff members.
9. (9) Completion of records. All health records shall be completed promptly. Reports of laboratory tests, treatments, and consultations shall be entered promptly on the health record.

10. (10) Vital Statistics Report. A record shall be kept of all births, deaths, and stillbirths that occur within the birthing center.

    1. (a) A certificate of birth for each live birth shall be filed with the Department's Center for Health Statistics, or as otherwise directed by the State Registrar, within 5 days after the birth, in accordance with Code of Ala. 1975, §22-9A-7 and Ala. Admin. Code r. 420-7-1-.03.
    2. (b) A report of fetal death shall be filed with the Center for Health Statistics, or as otherwise directed by the State Registrar, within 5 days after the occurrence is known if the fetus has advanced to, or beyond, the 20th week of uterogestation, in accordance with Code of Ala. 1975, § 22-9A-13 and Ala. Admin. Coder. 420-7-1-.03.
    3. (c) A certificate of death shall be filed with the Center for Health Statistics, or as otherwise directed by the State Registrar, within 5 days of the death, in accordance with Code of Ala. 1975 § 22-9A-14 and Ala. Admin. Coder. 420-7-1-.03 and -.10.
    4. (d) If a record of death or fetal death has not been created in the state's electronic registration system, the administrator or his/her designee must report to the Center for Health Statistics, or as otherwise directed by the State Registrar, any dead body or fetal death no later than the fifth day of the following month of which the body was handled by the birthing center.
    5. (e) All records and reports registered by the birthing center with the Center for Health Statistics shall be in a format prescribed by the State Registrar.
11. (11) Disposition of Records. When a birthing center ceases to operate either voluntarily or by revocation of its license, the governing body shall develop a proposed plan for the disposition of its medical records. Such plan shall be submitted to the State Board of Health and shall contain provisions for the proper storage, safeguarding, and confidential transfer and/or disposal of patient medical records and x-ray files. Any birthing center that fails to develop a plan for disposition of its records acceptable to the State Board of Health shall dispose of its records as directed by a court of appropriate jurisdiction.
12. (12) System of Periodic Review. There shall be a system for periodic record review and documentation of issues and outcomes.

Author: Dana Billingsley, Diane Milledge

Statutory Authority: Code of Ala. 1975, §22-2-2(6), et seq.; §22-21-20, et seq.

History: Filed November 19, 1987. Repealed: Filed April 16, 2010; effective May 21, 2010. New Rule: Published August 31, 2023; effective October 15, 2023.