A birth center shall maintain accurate and complete records on all of its patients.

1. (A) At a minimum, with respect to each newborn, the following information shall be included

   1. (1) The condition of the infant at birth to include APGAR Score (or its equivalent) at one minute and five minutes, time of sustained respiration, details of physical abnormalities and pathological states.
   2. (2) Date and hour of birth, birth weight and period of gestation.
   3. (3) Number of cord vessels and any abnormalities of the placenta.
   4. (4) Verification of eye prophylaxis.
   5. (5) Metabolic screening.
   6. (6) Treatments, medications and special procedures.
   7. (7) Condition at discharge or transfer.

1. (B) At a minimum, with respect to each pregnant and birthing person, the following information shall be included:

   1. (1) Birth person's medical and obstetric history including prenatal course.
   2. (2) Antenatal blood serology, Rh factor, blood type, HBsAg test, rubella antibody and Group B streptococcal culture results. In addition, results of maternal HIV testing, if applicable.
   3. (3) Admission examination including the condition of both the birthing person and fetus.
   4. (4) Complete description of progress of labor and delivery, signed by the attending physician or certified nurse midwife.
   5. (5) Names and credentials of all those present during delivery.
   6. (6) Description of postpartum course, including complications and treatments, signed by the attending certified professional midwife, physician or certified nurse midwife.
   7. (7) Medications, including contraceptives, prescribed at discharge.
   8. (8) Assessment, diagnosis, interventions and teaching.
   9. (9) Method of infant feeding and infant feeding plan of care and progress and documentation of lactation care and services provided.
   10. (10) If neonatal death occurs, cause of death, assessment of the family's coping mechanisms and plans for follow-up and/or referral of the family.