Title 7 . Health and Social Services

Chapter 12 . Assistance for Community Health Facilities

Section 425. Medical records

7 AAC 12.425. Medical records

(a) A birth center must keep records on all clients admitted. Originals or accurate reproductions of the contents of the originals of all records, including x-rays, must be maintained in a form which is legible and readily available upon the request of the collaborating physician, nurse midwife, representative of the department or, upon the client's written request, to other practitioners.

(b) Each medical record must include, as appropriate,

(1) an identification sheet which includes the

(A) client's name;

(B) medical record number;

(C) client's address on admission;

(D) client's date of birth;

(E) client's marital status;

(F) client's religious preference;

(G) date of admission;

(H) name, address, and telephone number of a contact person;

(2) an order sheet which includes medication, treatment, and diet orders signed by a midwife or collaborating physician;

(3) nurses' notes which include

(A) an accurate record of care given;

(B) a record of pertinent observations and response to treatment of the client including psychosocial and physical manifestations;

(C) an assessment at the time of admission;

(D) a discharge plan; and

(E) the name, dosage, and time of administration of a medication or treatment, the route of administration and site of injection if other than by oral administration, of a medication, the patient's response, and the signature of the person who administered the medication or treatment; and

(F) documentation that metabolic screening instructions were provided the client;

(4) laboratory reports;

(5) consent forms;

(6) labor record;

(7) delivery record;

(8) record of a neonatal physical examination and condition on discharge; and

(9) a discharge summary.

(c) A facility must maintain procedures to protect the information in medical records from loss, defacement, tampering, or access by unauthorized persons.

(d) Records must be indexed alphabetically according to patient's surname and filed according to a single identifying number.

(e) A transfer summary, signed by the midwife or collaborating physician, must accompany the client if the client is transferred to another facility. The transfer summary must include essential information relative to the client's diagnosis, condition, medications, treatments, dietary requirements, known allergies, and treatment plan.

History: Eff. 5/14/82, Register 82; am 11/19/83, Register 88

Authority: AS 18.05.040