Kan. Admin. Regs. § 28-4-1307 - Records
Current through Register Vol. 40, No. 39, September 30, 2021
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28-4-1307. Records. (a) Policies and procedures. Each licensee shall ensure that there is an organized recordkeeping 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 inservice 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. (Authorized by K.S.A. 65-508; implementing K.S.A. 65-507 and 65-508; effective July 9, 2010.)