Or. Admin. R. 332-025-0110 - Records of Care Practice Standards
(1) The LDM must maintain complete and
accurate records of each birthing person and newborn.
(2) Records mean written or electronic
documentation, including but not limited to:
(a) Midwifery care provided to birthing
person and newborn;
(b) Demographic
information;
(c) Medical
history;
(d) Diagnostic studies and
laboratory findings;
(e) Emergency
transport plan OAR 332-025-0021;
(f) Informed consent and risk information
documentation under OAR 332-025-0120;
(g) Health Insurance Portability and
Accountability Act (HIPAA) releases;
(h) Documentation of all consultations
pursuant to OAR 332-025-0021 (14) through (22) and recommendations regarding
indications for consultation from an Oregon licensed health care provider as
defined under OAR 332-025-0021(21), or any other provider specifically
identified in OAR 332-025-0021;
(i)
Documentation of any declined procedures (OAR 332-025-0022(7));
(j) Documentation of termination of care (OAR
332-025-0130); and
(k)
Documentation that the birthing person received and signed the patient
disclosure form (OAR 332-025-0020(6)).
(3) Records, including metadata, must be
maintained for no less than five years. All records are subject to review by
the Office.
(4) All entries must
include the LDM's initials and be legibly written or typed and dated.
(5) Entries made 48 hours after an
event must be identified as an addendum or an amended entry and must include
the date and time of entry and the LDM's initials.
(6) All records must include a signature or
initial of the LDM.
Notes
Statutory/Other Authority: ORS 676.615 & ORS 687.480
Statutes/Other Implemented: ORS 687.480
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