b) Each birth center shall maintain accurate and complete clinical records for each client, and all entries in the clinical record shall be made at the time when care, treatment, medications, consultations, or other medical services are given. The record shall include, but not be limited to, the following:

1. 1) Client-identifying information;
2. 2) Name of the client's birth attendants, and the name of all other birth assistants;
3. 3) Initial risk assessment in accordance with Section 264.1550(f);
4. 4) A disclosure statement and informed consent that is signed by the client that explains the benefits, limitations, and risks of the services available at the center, and that describes the collaborative arrangements that the center has with physicians and with referral hospitals;
5. 5) Record of antepartum (prenatal) care;
6. 6) History and physical examination of the client;
7. 7) Laboratory tests, ultrasounds, procedures and results;
8. 8) Written progress notes, signed and dated by the person rendering the service, and incorporated into the client record within 24 hours after services;
9. 9) Medication list and medication administration record, if applicable;
10. 10) Intrapartum care;

11. 11) Newborn assessment and care, including, but not limited to:

    1. A) Apgar scores;
    2. B) Maternal-newborn interaction;
    3. C) Prophylactic procedures;
    4. D) Accommodation to extra-uterine life;
    5. E) Blood glucose when clinically indicated;
    6. F) Supplemental oxygen;
    7. G) Newborn screening required per the Hearing Screening and Vision Screening administrative codes and the Newborn Metabolic Screening and Treatment Code.
12. 12) Postpartum care;
13. 13) Allergies and medication reactions;
14. 14) Documentation of consultation;
15. 15) Refusal of the client to comply with advice or treatment;
16. 16) Discharge summary, to include postpartum person and infant;
17. 17) Discharge plan and instructions to the client;
18. 18) Arrangements for newborn follow-up screening and testing it the newborn is discharged prior to the 48 hours;
19. 19) Authentication of entries by the physician or physicians, birth attendants and birth assistants who treated or cared for the client and newborn;
20. 20) A copy of the transport form if the client or newborn was transferred to the referral hospital; and
21. 21) Documentation that a birth certificate was filed or, if applicable, a death certificate was filed.