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Oklahoma Administrative Code (Last Updated: March 11, 2021) |
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TITLE 310. Oklahoma State Department of Health |
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Chapter 616. Birthing Centers Regulations |
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Subchapter 3. Administration |
SECTION 310:616-3-3. Reports and records
Latest version.
- (a) Reports. Reports shall be made by the birthing center to the appropriate agency, including but not limited to the following:(1) Communicable diseases.(2) Births and deaths.(3) Periodic reports to the Department on forms supplied for this purpose.(4) Newborn hearing screening report.(5) Newborn metabolic screening.(6) Birth defects.(b) Retention and preservation of records.(1) State retention requirements. Medical records will be retained a minimum of five years beyond the date the patient was last seen or a minimum of three years beyond the date of the patient's death.(2) Preservation of records. Birthing centers generating medical records may microfilm the medical records and destroy the original record in order to conserve space.(c) Record of care.(1) The birthing center shall establish and maintain a medical record for each mother and infant receiving care and services. The record shall be complete, timely and accurately documented, and readily accessible.(2) The medical record shall contain sufficient information to justify the diagnosis and treatment and warrant the services provided. Entries are made and signed by the person providing the services. The record shall include all care and services whether furnished directly or under arrangement made by the center. Each record shall contain at least, but not limited to, the following:(A) Identification data.(B) Initial and subsequent assessments.(C) Record of prenatal care.(D) Medical history and physical exam.(E) Risk assessment.(F) Allergies and medication reactions.(G) A disclosure statement signed by the patient explaining the principles of midwifery, benefits, limitations, and risks available to them at the birthing center and describing the arrangements the center has with physicians and the referral hospitals.(H) Plan of care.(I) Laboratory reports.(J) X-Ray reports.(K) Intrapartum care.(L) Postpartum care.(M) Newborn care.(N) Patient's compliance to advice and/or treatment.(O) Discharge Summary.