1. (a) The medical record for each patient shall contain the following information:

   1. (1) results of physical and risk assessments;
   2. (2) patient history, to include medical, surgical, gynecological and psychosocial history;
   3. (3) record of informed consent, including shared decision making, for midwifery birth center services;
   4. (4) ongoing assessments of fetal growth and development;
   5. (5) periodic evaluations of patient health;
   6. (6) results of laboratory tests;
   7. (7) labor and birth information;
   8. (8) newborn patient physical assessment, including APGAR scores, maternal-newborn interaction, ability to feed, eye prophylaxis, vital signs and accommodation to extrauterine life;
   9. (9) postpartum assessment;
   10. (10) discharge and follow-up plans;
   11. (11) home visit reports;
   12. (12) midwifery birth center follow-up visit report; and
   13. (13) documentation of family planning counseling and the arrangements made for family planning services, if any.

2. (b) The medical record for each newborn shall be cross-referenced with the patient’s medical record and contain the following information:

   1. (1) copy of the newborn physical assessment;
   2. (2) results from newborn screening tests;
   3. (3) discharge summary with follow-up plans; and
   4. (4) home visit report.

The operator shall ensure that, in addition to meeting the requirements in section 751.7 of this Title: