Ch. 26, § 16. Records

(a) If a patient receives services at a center, the center shall maintain a patient medical record. As applicable, a patient medical record must include: (i) Regarding a pregnant woman or mother: (A) Documentation of prenatal care, including: (I) A complete blood count; (II) Urinalysis; (III) Prenatal blood serology; (IV) Rhesus factor (Rh) determination and evidence of a plan for the appropriate use of Rh immune globulin; (V) Past obstetrical history; (VI) Physical examination; (VII) Rubella titer; (VIII) Identification data including patient history and physical examination; (IX) Signed consent; (X) Medication orders signed by licensed provider (Physician, CNM or CPM); and (XI) Other laboratory test results. (ii) Regarding the labor and delivery: (A) Documentation of the labor and delivery: (I) Anesthesia and analgesia and medication given in the course of labor, delivery, and postpartum; (II) Administration of rhesus (Rh) immune globulin, if any; (III) Recovery and other progress notes; (IV) Medications administered; (V) Condition and referral on discharge; and (VI) Home visits following discharge. (iii) Regarding a newborn: (A) Documentation of newborn care, including: (I) Date and hour of birth; (II) Birth weight: (III) Length; (IV) Estimation of gestational age; (V) Gender; (VI) Condition of infant on delivery including APGAR; (VII) Record of ophthalmic prophylaxis and Vitamin K, or refusal thereof; (VIII) Appropriate physical examination at birth and at discharge by physician or midwife; (IX) Genetic screening, phenylketonuria (PKU) or other metabolic disorders report or refusal thereof; and (X) Fetal monitoring record. (b) A center shall register a birth according to W.S. 35-1-410 and Rules, Wyoming Department of Health, Vital Records Services, Chapter 3 (2008). A center shall include the birth registration information as part of the medical record. (c) A center shall comply with the Health Insurance Portability and Accountability Act (HIPAA) of 1996, the implementing regulations of HIPAA, and any other applicable law relating to the maintenance or disclosure of health information. (d) A center shall maintain all records according to professional standards of practice, including storage of records in a secure and designated area. (e) A center's medical records policy must: (i) Ensure the confidentiality of medical records and safeguard against loss, destruction, or unauthorized use, in accordance with applicable law; (ii) Govern the use and removal of records from the record storage area; (iii) Specify the conditions under which record information may be released and to whom; (iv) Specify when the patient's written consent is required for release of information; (v) Ensure all entries are dated, signed, and legible; (vi) Ensure all information to a patient's care and stay is documented in the patient's medical record; and (vii) Ensure that medical records are preserved in physical or electronic form. (f) A center shall maintain personnel records for each individual employed at the center that include: (i) An employment application; (ii) Verification of criminal background check and Central Registry check; (iii) Licensure verification; (iv) Copies of certifications required under Section 17; (v) Immunizations and other medical tests; and (vi) Results of medical examinations required as a part of employment. (g) A center shall maintain equipment records per the manufacturer's recommendations.