Utah Admin. Code R432-550-20 - Medical Records
(1) Medical records
shall be complete, accurately documented and systematically organized to
facilitate retrieval and compilation of information.
(2) An employee designated by the
administrator shall be responsible and accountable for the processing of
medical records.
(3) The medical
record and its contents shall be safeguarded from loss, defacement, tampering,
fires and floods.
(4) Medical
records shall be protected against access by unauthorized individuals. Birthing
centers shall:
(a) keep medical record
information confidential; and
(b)
obtain consent from the patient before releasing client information identifying
the client, including photographs, unless release is otherwise allowed or
required by law.
(5)
Medical records shall be retained for at least five years after the last date
of patient care. Records of minors, including records of newborn infants, shall
be retained for three years after the minor reaches legal age under Utah law,
but in no case less than five years.
(6) The birthing center shall maintain an
individual medical record for each patient which shall include but is not
limited to written documentation of the following:
(a) admission record with demographic
information and patient identification data;
(b) history and physical examination which
shall be up-to-date upon the patient's admission;
(c) written and signed informed
consent;
(d) orders by a clinical
staff member;
(e) record of
assessments, plan of care and services provided;
(f) record of medications and treatments
administered;
(g) laboratory and
radiology reports;
(h) discharge
summary for mother and newborn to include a note of condition, instructions
given and referral as appropriate;
(i) prenatal care record containing at least
prenatal blood serology, Rh factor determination, past obstetrical history and
physical examination and documentation of fetal status;
(j) monitoring of progress in labor with
assessment of maternal and newborn reaction to the process of labor;
(k) fetal monitoring record;
(l) labor and delivery record, including type
of delivery, record of anesthesia and operative procedures if any;
and
(m) documentation that the
patient is informed of the statement of patient rights.
(7) The records of newborn infants shall
include the following:
(a) date and hour of
birth, birth weight and length, period of gestation, gender and condition of
infant on delivery including Apgar scores and resuscitative measures;
(b) mother's name or unique
identification;
(c) record of
ophthalmic prophylaxis; and
(d) the
identification number of the screening kit used to screen for metabolic
diseases, documentation that metabolic screening, genetic screening, PKU or
other metabolic disorders reports were completed or refused by the
client.
(8) An alongside
midwifery unit may integrate medical records with the medical record system of
the adjoining hospital.
Notes
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