Kan. Admin. Regs. § 28-4-1307 - Records
(a) Policies and
procedures. Each licensee shall ensure that there is an organized
re-cordkeeping system, with policies and procedures that provide for
identification, security, confidentiality, control, retrieval, and preservation
of all employee records, patient records, and birth center information. All
records shall be available at the birth center for review by the
secretary.
(b) Employee records.
Each licensee shall ensure that an individual record is maintained at the birth
center for each employee that includes the following information:
(1) A description of the terms of employment
or the volunteer agreement and a copy of the job description;
(2) a copy of the job application detailing
the employee's qualifications and employment dates;
(3) copies of current professional licenses,
certifications, or registrations;
(4) documentation of the results of any
health assessments and tuberculin tests specified in K.A.R. 28-4-1312
;
(5) documentation of the
orientation and the in-service training specified in K.A.R. 28-4-1306 ;
and
(6) documentation that each
employee has access to the following:
(A) The
current regulations governing birth centers; and
(B) the birth center policies, procedures,
and clinical protocols.
(c) Patient records.
(1) Each licensee shall ensure that a current
and complete clinical record for each patient accepted for care in the birth
center includes the following:
(A)
Identifying information, including the patient's name, address, and telephone
number;
(B) documentation of the
initial history and physical examination, including laboratory findings and
dates;
(C) a signed and dated
informed consent form;
(D) all
obstetrical risk assessments, including the dates of the assessments;
(E) documentation of instruction and
education related to the childbearing process;
(F) the date and time of the onset of
labor;
(G) the course of labor,
including all pertinent examinations and findings;
(H) the exact date and time of birth, the
presenting part of the newborn's body, the sex of the newborn, the numerical
order of birth in the event of more than one newborn, and the Apgar scores;
(I) the time of expulsion and the
condition of the placenta;
(J) all
treatments rendered to the patient and newborn, including prescribing
medications and the time, type, and dose of eye prophylaxis;
(K) documentation of metabolic and any other
screening tests completed by a clinical staff member;
(L) the condition of the patient and newborn,
including any complications and action taken at the birth center;
(M) all medical consultations concerning the
patient and the newborn;
(N) all
referrals for medical care and transfers to medical care facilities, including
the reasons for each referral or transfer;
(O) the results of all examinations of the
newborn and of the postpartum patient; and
(P) the written instructions given to the
patient regarding postpartum care, family planning, care of the newborn,
arrangements for metabolic testing, immunizations, and follow-up pediatric
care.
(2) Each entry in
each patient's record shall be dated and signed by the attending clinical staff
member.
(3) The patient record
shall be confidential and shall not be released without the written consent of
the patient. Nothing in this regulation shall preclude the review of patient
records by the secretary.
(4) All
patient records shall be retained for at least 25 years from the date of
discharge.
(d) Quality
assurance documentation. Each licensee shall maintain on file for at least
three calendar years all documentation required for the quality assurance
findings specified in K.A.R. 28-4-1309.
(e) Inventory. Each licensee shall maintain
on file an inventory of the birth center furnishings, equipment, and
supplies.
(f) Drills. Each licensee
shall maintain on file for at least one calendar year a record of all disaster
and evacuation drills.
(g) Changes.
Each applicant and each licensee shall maintain on file at the birth center the
documentation of any changes specified in K.A.R. 28-4-1304 and approved by the
secretary.
Notes
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