LAC 48:I.9565
LAC 48:I.9565. Medical Records Requirements
Cite as La. Admin. Code tit. 48, pt. I, § 9565
A. The medical record of the mother and newborn shall include, but not be limited to, the following documentation:
1. informed consent signed by the patient and the CNM;
2. demographic and patient information;
3. family, medical, social, reproductive, nutrition and behavioral history;
4. initial maternal assessment and examination;
5. evaluation of maternal/fetal risk factors;
6. written orders for maternal/fetal and newborn care;
7. laboratory and/or diagnostic test results;
8. documentation of maternal/fetal and newborn monitoring;
9. postpartum assessments;
10. physical assessment of newborn, e.g., Apgar score, weights, measurements;
11. labor and discharge summaries; and
12. educational instructions for postpartum and newborn home care, follow ups, and referrals.