1. (a)

   1. (1) The freestanding birthing center shall maintain a system for the completion and storage of the medical record.

   2. (2) The record shall provide a format for continuity and documentation of legible, uniform, complete, and accurate maternal and infant information:

      1. (A) Readily accessible; and
      2. (B) Maintained in a system that ensures confidentiality.

2. (b) General requirements.

   1. (1) The freestanding birthing center shall adopt a record form for use that contains information required for transfer to an acute care maternal and newborn service.
   2. (2) Record reviews with criteria for identification of problems and follow-up shall be reported to the QI Committee quarterly.
   3. (3) Responsibility for the processing of records is assigned to an individual employed by the freestanding birthing center.
   4. (4) All medical records shall be retained in either the original, microfilm, or other acceptable methods for ten (10) years after the last discharge.
   5. (5) Complete medical records of minors shall be retained for a period of two (2) years after the age of majority is reached.
   6. (6) The original, or a copy of the original when the original is not available, of all reports shall be filed in the medical record.
   7. (7) The record shall be permanent and shall be either typewritten or legibly written in blue or black ink.
   8. (8) All typewritten reports shall include the date of dictation and the date of transcription.
   9. (9) All dictated records shall be transcribed within forty-eight (48) hours.

   10. (10) Errors shall be corrected by:

       1. (A) Drawing a single line through the incorrect data;
       2. (B) Labeling it as "Error"; and
       3. (C) Initialing and dating the entry.
   11. (11) Birth certificates shall be completed according to the Rules for the Administration of Vital Records, 20 CAR pt. 1, Department of Health.

   12. (12)

       1. (A) Policies and procedures for Health Information Services shall be developed.
       2. (B) The manual shall have evidence of ongoing review and/or revision.
       3. (C) The first page of the manual or manuals shall have the:

3. (i) Annual review date; and

   1. (ii) Signature of the department supervisor and/or person or persons conducting the review.

   2. (13) Medical records shall be protected to ensure:

      1. (A) Confidentiality;
      2. (B) Prevention of loss; and
      3. (C) Availability on a twenty-four-hour basis.
   3. (14) All medical records, whether stored within the facility or away from the facility, shall be protected from destruction by fire, water, vermin, dust, etc.

   4. (15)

      1. (A) Medical records shall be considered confidential.
      2. (B) All medical records, including those filed outside the facility, shall be secured at all times.
      3. (C) Records shall be available to authorized personnel from the Department of Health.

   5. (16)

      1. (A) Written consent of the patient or legal guardian shall be presented as authority for release of medical information.
      2. (B) There shall be policies and procedures developed concerning all phases of release of information.
   6. (17) Original medical records shall not be removed from the facility except upon receipt of a subpoena duces tecum by a court having authority for issuing such an order.
   7. (18) Medical records shall be complete and contain all required signed documentation no later than thirty (30) days following the patient's discharge date.

   8. (19)

      1. (A) Medical records shall be destroyed by burning or shredding.

      2. (B) Medical records shall not be disposed of in:

         1. (i) Landfills; or
         2. (ii) Other refuse collection sites.

   9. (20)

      1. (A) Each entry into the medical record shall be authenticated by the individual who is the source of the information.

      2. (B) Entries shall include:

         1. (i) Observations;
         2. (ii) Notes; and
         3. (iii) Other information included in the record.

   10. (21)

       1. (A) Signatures shall be at least the:

          1. (i) First initial;
          2. (ii) Last name; and
          3. (iii) Title.
       2. (B) Computerized signatures by code, number, initials, or the method developed by the facility are acceptable.

   11. (22) There shall be policies and procedures approved by the Department of Health for use of computerized medical records.

       1. (c) Record content. Each record shall include but not be limited to documentation of:
   12. (1) Demographic and patient information;
   13. (2) Orientation to program and informed consent;
   14. (3) Complete family, medical, social, reproductive, nutrition, and behavioral history;
   15. (4) Initial physical examination, evaluation of risk status, and laboratory test result;
   16. (5) Appropriate referral of patients who did not meet the freestanding birthing center criteria on the initial screening;
   17. (6) Documentation of each periodic examination and evaluation of risk factors;

   18. (7) Instructions and education including:

       1. (A) Changes in pregnancy;
       2. (B) Self-care;
       3. (C) Nutritional counseling;
       4. (D) Preparation for labor;
       5. (E) Family preparation;
       6. (F) Explanation on examinations and laboratory tests; and
       7. (G) Newborn assessment and care;
   19. (8) Monitoring of labor progress;
   20. (9) Physical assessment of newborn, e.g., Apgar score;
   21. (10) Labor and discharge summaries;
   22. (11) Home care, follow-up, and referrals; and
   23. (12) Informed consent signed by the patient.

Codification Notes: “QI” means quality improvement.