048-6 Wyo. Code R. §§ 6-10 - Medical Records

The birthing center shall maintain a separate medical record for each patient in accordance accepted professional standards for the purpose of continuity and evaluation of care, preservation as a legal document and as an aid in teaching and training. The birthing center shall maintain written policies and procedures for the preparation, completion, confidentiality, accessibility and preservation of medical records to include but not be limited to the following standards:

(a) Staffing.

(1) The administrator shall designate in writing an employee who is responsible for medical record functions.

(2) Services of a qualified medical record consultant, who is a Registered Record Administrator (RRA) or Accredited Record Technician (ART), shall be provided at least twice a year and shall document all consultant activities.

(b) Protection of Medical Record Information.

(1) The medical record, either in original or microfilm form, shall not be removed from the control of the birthing center except upon receipt of a subpoena duces tecum or the specific written authorization of the administration. Medical records are the property of the birthing center.

(2) The birthing center shall have written policies and procedures regarding access to medical records and release of information.

(3) Written consent of the patient (or the responsible person acting in her behalf) shall be recurred for release of information not authorized by law.

(4) Authorized personnel of the Division shall be permitted to review medical records as necessary to determine compliance with these rules.

(c) Content of Medical Record. All entries shall be dated and signed and shall be made legibly in ink or typescript.

(1) The medical record shall include at least the following:

(a) Admitting identification data including patient history and physical examination;

(b) Signed consent;

(c) Medication orders counter-signed by physician;

(d) Laboratory tests;

(e) Anesthesia record;

(f) Recovery and other progress notes;

(g) Record of all medications and treatments ordered and administered;

(h) Condition and referral on discharge;

(i) Records of home visits following discharge.

(2) Obstetrical records shall include in addition to the requirements for medical records the following:

(a) Prenatal record containing at least a CBC, UA, prenatal blood serology, Rh factor determination, past obstetrical history, physical examination and a rubella titer;

(b) Labor and delivery record;

(c) Records of anesthesia and analgesia and medication given in the course of labor, delivery, and postpartum;

(d) Record of administration of RH immune globulin if any.

(3) Records of newborn infants shall include in addition to the requirements for medical records the following information:

(a) Date and hour of birth, birth weight and length, period of gestation; sex; and condition of infant on delivery (Including APGAR)

(b) Mother's name and birthing center number, and/or similar identification;

(c) Record of ophthalmic prophylaxis;

(d) Appropriate physical examination at birth and at discharge by physician/midwife;

(e) Genetic screening, PKU or other metabolic disorders report;

(f) Fetal monitoring record;

(g) Hospital copy of birth certificate.

(d) Completion of Records and Centralization of Reports.

(1) The medical records shall be completed and filed within 30 days of the patient's discharge.

(2) All information pertaining to a patient's stay shall be centralized in the patient's medical record.

(3) An original birth certificate shall be deleted and sent to the local registrar. A hospital copy is preserved in the newborn's record.

(4) A copy of the patient's medical record, an abstract thereof, or a referral form shall accompany the patient transferring to another health care facility.

(e) Retention of Records.

(1) Records of private birthing centers shall be preserved permanently in the original or microfilm form. Public birthing centers shall refer to the Archives and Records Management Division, Wyoming State Archives, Museum and Historical Department; Barrett Building; Cheyenne, WY; for retention directives.

(2) In the event of dissolution of the birthing center, the administrator shall notify the Division as to the location of medical records.

(f) Index. A system of identification and filing to ensure the rapid retrieval of medical records shall be maintained.

(1) Patient index shall include at least: full name of patient, date of birth, medical record number, date of admission and discharge, length of stay; other information necessary by the birthing center.

(g) Maintenance and Storage.

(1) There shall be adequate space and operable equipment to provide efficient systematic processing of medical records.

(2 Storage space shall be easily accessible and secure from unauthorized access or damage by water, fire, or hazards.

Notes

048-6 Wyo. Code R. §§ 6-10