1. (a) A midwife shall establish and maintain a record of the care provided and the data gathered for each client and newborn.

2. (b) Each client’s record shall contain the following information, as applicable:

   1. (1) The client's identification information including:

      1. a. Name;
      2. b. Address;
      3. c. Telephone number;
      4. d. Date of birth;
      5. e. Marital status;
      6. f. Name of spouse or partner, if any; and
      7. g. Emergency contact person;
   2. (2) The client’s health history;

   3. (3) Notes documenting the midwife's actions and guidance during personal and telephone contacts between:

      1. a. The client and the midwife; and
      2. b. The client’s spouse or partner and the midwife;

   4. (4) The dates and findings of:

      1. a. Prenatal care given pursuant to Mid 502.03(a); and
      2. b. Extended postpartum care given pursuant to Mid 502.07;
   5. (5) Results of consultations with physicians or other health care providers;
   6. (6) Laboratory and diagnostic reports;
   7. (7) Documentation of all medications administered to the client;
   8. (8) The signed originals of all forms required by these rules or other law to be signed by the client;
   9. (9) The name and phone number of the health care provider chosen by the client to care for the newborn;
   10. (10) Contemporaneously recorded details of the labor, the birth and the immediate postpartum period, annotated with the date and time for each entry;
   11. (11) The midwife's written summary of the most important facts of the labor, the birth, and the assessment of the newborn; and
   12. (12) The reasons for any transfer of the client's care.
3. (c) A midwife shall, with the written consent of the client, provide the newborn’s health care provider with a copy of the summary required by (b)(11) above.

4. (d) A midwife shall retain each client’s records for the longer of the following:

   1. (1) A period of 21 years from the date of birth of a baby born while the client was in the care of the midwife; or
   2. (2) A period of 7 years from the date of the midwife's last contact with the client if no baby was born while the client was in the care of the midwife.

Source. #8840, eff 3-13-07, EXPIRED: 3-13-15 New. #11095, INTERIM, eff 5-12-16, EXPIRED: 11-8-16 New. #12040, eff 11-10-16