Records

(A) Maternal Record. The obstetrics service shall establish and maintain a system for obtaining prenatal records or summaries of records of patients at 24 weeks of pregnancy (with updates as warranted in accordance with hospital policy) and for making them available to the staff of the labor and delivery unit when the patient is admitted for delivery. Such records shall be maintained as part of the mother’s permanent record. In addition to the requirements for all hospital patient records, the mother’s record shall include: (1) Mother’s medical and obstetric history including prenatal course. (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) Admission obstetrical examination including the condition of both mother and fetus. (4) Complete description of progress of labor and delivery, signed by the attending physician, or certified nurse midwife, including reasons for induction and operative procedures. (5) Type of medications, analgesia and anesthesia administered to the patient during labor and delivery. (6) Signed report of qualified obstetric or other consultant when such service has been obtained. (7) Names and credentials of all those present during delivery. (8) Description of postpartal course, including complications and treatments, signed by the attending physician or certified nurse midwife. (9) Medications, including contraceptives, prescribed at discharge. (10) Infant’s condition at birth including gestational age, weight, Apgar score, blood type, and results of initial physical assessment. (11) Nursing assessment, diagnosis, interventions and teaching. (12) Method of infant feeding and infant feeding plan of care and progress and documentation of lactation care and services provided. (13) 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. (B) Newborn Record. In addition to the requirements for all patient records, the newborn record shall include: (1) Significant maternal diseases. (2) Mother’s obstetric history including estimated date of confinement and prenatal care course. (3) Maternal antenatal blood serology, typing, Rh factors, rubella antibody titer, coombs test for maternal antibodies if indicated, and prenatal HBsAg test results. (4) Results of anysignificant prenatal diagnostic procedures including genetic testing and/or chromosomal analysis. (5) Complications of pregnancy or delivery. (6) Duration of ruptured membranes. (7) Medications, analgesic and/or anesthesia administered to the mother. (8) Complete description of progress of labor including diagnostic tests, treatment rendered and reasons for induction or operative procedures. (9) Date and time of birth. (10) Cause of death if it occurs. (11) Condition of the infant at birth including Apgar score, resuscitation, time of sustained respirations, description of congenital anomalies, gestational age, head circumference, length, weight, pathological conditions and treatments. (12) Number of cord vessels and description of any placental anomalies. (13) Written verification of eye prophylaxis, vitamin K and mandated screening tests, including time and date. (14) Infant Feeding. (a) Method of feeding including feeding plan of care. (b) Documentation of at least two successful feedings, for both breastfeeding and formula fed infants. (15) Report of infant’s initial medical examination within 24 hours of birth, signed by the infant’s attending physician or his or her physician designee or neonatal nurse practitioner. (16) Informed consent for circumcision or any other surgical procedures. (17) Physician progress notes written in accordance with hospital policy. (18) A report of discharge examination signed by attending physician, certified nurse midwife pediatric nurse practitioner or neonatal nurse practitioner within 24 hours of discharge. (19) Nursing assessment, diagnosis, interventions and teaching. (20) Documentation that hearing screening has been performed, screening results and referral, if any. If a referral is made, the medical record shall document the date, time and location of the follow-up appointment. (21) Discharge instruction sheet including feeding plan, referrals and follow-up care signed by the infant’s practitioner.