Ariz. Admin. Code § R9-16-115 - Client and Newborn Records
A. A
midwife shall ensure that a record is established and maintained according to
A.R.S. §§
12-2291 and
12-2297 for each:
1. Client, and
2. Newborn delivered by the midwife from a
client.
B. A midwife
shall ensure that a record for each client includes the following:
1. The client's full name, date of birth,
address, and client number;
2.
Names, addresses, and telephone numbers of the client's spouse or other
individuals designated by the client to be contacted in an emergency;
3. Written informed consent for midwifery
services, as required in
R9-16-108(C)(2)
;
4. If applicable, assertion to
decline required tests, as required in
R9-16-110(A)
;
5. A copy of the emergency care
plan, as required in
R9-16-108(D)
;
6. The date the midwife began
providing midwifery services to the client;
7. The date the client is expected to deliver
the newborn;
8. The date the
newborn was delivered, if applicable;
9. An initial assessment of the client to:
a. Determine whether the client has a history
of a condition or circumstance that would preclude care of the client by the
midwife, as specified in
R9-16-111 ; and
b. Determine the:
i. Number and outcome of previous
pregnancies, and
ii. Number of
previous medical or midwife visits the client has had during the current
pregnancy;
10. Progress notes documenting the midwifery
services provided to the client;
11. For a delivery identified in
R9-16-108(B):
a. Rate of dilation, and
b. Duration of second stage labor;
12. Laboratory and diagnostic
reports, required in
R9-16-108(I)
;
13. Documentation of
consultations as required in
R9-16-112, including:
a. Reason for the consultation,
b. Name of physician or certified nurse
midwife contacted,
c. Date of
consultation,
d. Time of
consultation,
e. Recommendation
made by the physician or certified nurse midwife, and
f. Actions taken as a result of the
consultation;
14. Any
written reports received from consultations required in
R9-16-112 ;
15. A description of any conditions or
circumstances arising during the pregnancy that required the transfer of
care;
16. The name of the
physician, certified nurse midwife, or hospital to which the care of the client
was transferred, if applicable;
17.
Documentation of medications or vitamins taken by the client;
18. Documentation of medications or vitamins
administered to the client and the physician's written orders for the
medications or vitamins;
19. The
outcome of the pregnancy;
20. The
date the midwife stopped providing midwifery services to the client;
and
21. Instructions provided to
the client before the midwife stopped providing midwifery services to the
client.
C. A midwife
shall ensure that a record for each newborn includes the following:
1. The full name, date of birth, and address
of the newborn's mother;
2. The
newborn's:
a. Date of birth,
b. Gender,
c. Weight at birth,
d. Length at birth, and
e. Apgar scores at one minute and five
minutes after birth;
3.
The newborn's estimated gestational age at birth;
4. Progress notes documenting the midwifery
services provided to the newborn;
5. Laboratory and diagnostic reports, as
required in
R9-16-108(I)
;
6. Documentation of consultations
as required in
R9-16-112, including:
a. Reason for the consultation,
b. Name of physician or certified nurse
midwife contacted,
c. Date of
consultation,
d. Time of
consultation,
e. Recommendation
made by the physician or certified nurse midwife, and
f. Actions taken as a result of the
consultation;
7. Any
written reports received from consultations required in
R9-16-112 ;
8. A description of any conditions or
circumstances arising during or after the newborn's birth that required the
transfer of care;
9. The name of
the physician, certified nurse midwife, or hospital to which the care of the
newborn was transferred, if applicable;
10. Documentation of medications or vitamins
taken by the newborn;
11.
Documentation of medications or vitamins administered to the newborn and the
physician's written orders for the medications or vitamins;
12. Documentation of newborn screening,
including when the specimen collection kit, as defined in A.A.C.
R9-13-201, was submitted and
results received, as required in
R9-16-108(K)(4)(c)
;
13. The date the midwife stopped
providing midwifery services to the newborn; and
14. Instructions provided to the client about
the newborn before the midwife stopped providing midwifery services to the
newborn.
Notes
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