(a) The medical record for each woman admitted to the birth center shall contain the following information:
- (1) results of physical and risk assessments;
- (2) maternal history, to include medical, surgical, gynecological and psychosocial history;
- (3) informed consent for birth center services;
- (4) ongoing assessments of fetal growth and development;
- (5) periodic evaluations of maternal health;
- (6) results of laboratory tests;
- (7) labor and birth information;
- (8) newborn physical assessment, including APGAR scores, maternal-newborn interaction, ability to feed, eye prophylaxis, vital signs and accommodation to extrauterine life;
- (9) postpartum assessment;
- (10) discharge and follow-up plans;
- (11) home visit reports;
- (12) birth center follow-up visit report; and
- (13) documentation of family planning counseling and the arrangements made for family planning services, if any.
(b) The medical record for each newborn shall be cross-referenced with the mother's medical record and contain the following information:
- (1) copy of the newborn physical assessment;
- (2) results from newborn screening tests;
- (3) discharge summary with follow-up plans; and
- (4) home visit report.
The operator shall ensure that, in addition to meeting the requirements in section 751.7 of this Title: