Authority: IC 16-21-1-7; IC 16-21-2-2.5

Affected: IC 16-21-1

Sec. 2. (a) The medical record must contain sufficient information to do the following:

1. (1) Identify the patient.
2. (2) Document tests, examinations, and procedures performed.
3. (3) Document accurately the course of the patient's stay in the center and the results.

(b) All entries in the medical record must be as follows:

1. (1) Legible.
2. (2) Complete.
3. (3) Made by authorized individuals as specified in center and medical staff policies.
4. (4) Authenticated and dated in accordance with this article.

(c) All patient records must document and contain, at a minimum, the following:

1. (1) Patient identification and demographics.

2. (2) Complete:

   1. (A) social;
   2. (B) family;
   3. (C) medical;
   4. (D) reproductive;
   5. (E) nutrition; and
   6. (F) behavioral;
3. history.
4. (3) Initial physical examination, laboratory tests, and evaluation of risk status.
5. (4) Appropriate referral on ineligible clients with report of findings on initial screening.
6. (5) Continuous periodic prenatal examination and evaluations of risk factors.

7. (6) Instruction and education to include, but not be limited to, the following:

   1. (A) Nutritional counseling.
   2. (B) Self care and changes in pregnancy.
   3. (C) Understanding of findings of examinations, studies, and laboratory tests.
   4. (D) Preparation for labor.
   5. (E) Sibling preparation, if applicable.
   6. (F) Preparation for early discharge.
   7. (G) Newborn assessment and care.
8. (7) Preadmission diagnostic studies if performed.
9. (8) History, physical examination, and risk assessment on admission to the center.
10. (9) Monitoring of progress in labor and assessment of maternal and newborn reaction to labor in accordance with accepted professional standards.
11. (10) Consultation, referral, and transfer for maternal and neonatal problems that elevate risk status.

12. (11) Newborn assessment including the following:

    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.
13. (12) Maternal assessments during recovery.
14. (13) Summary of labor.
15. (14) Discharge summary to include mother and infant.
16. (15) Discharge plan and instructions.
17. (16) Any allergies and abnormal drug reactions.
18. (17) Evidence of appropriate informed consent for procedures and treatments consistent with state law.
19. (18) Authentication of entries by the physician or physicians and health care workers who treated or cared for the patient.
20. (19) A copy of the transfer form if the patient was referred to a hospital or other facility.

(Indiana Department of Health; 410 IAC 27-7-2; filed Feb 3, 2006, 2:00 p.m.: 29 IR 1913; readopted filed Jul 12, 2012, 12:09 p.m.: 20120808-IR-410120265RFA; readopted filed Sep 26, 2018, 2:48 p.m.: 20181024-IR-410180328RFA; readopted filed Nov 14, 2024, 1:24 p.m.: 20241211-IR-410230798RFA)