W. Va. Code R. § 64-31-11 - Records

11.1. The birthing center shall maintain a clinical record system, policies and procedures which provide for identification, security, confidentiality, control, retrieval and preservation of client care data and information.

11.2. There shall be a health record maintained for each maternal and newborn client to include:

(a) personal and family history;

(b) physical examination;

(c) reports of relevant laboratory tests and screening procedures;

(d) newborn and maternal status during the prenatal period, labor, birth, recovery and follow-up;

(e) reports of any outside tests, examinations and treatments requested by the birthing center during the course of care of the maternal and newborn client;

(f) all services provided to both the maternal and the newborn client; and

(g) documentation and authentication by staff who order or who administer drugs or treatments or who make observations or assessments.

11.3. Entries in the client record shall be typewritten or written legibly in ink.

11.4. Documentation and record keeping shall include completion of birth or death certificates.

11.5. Records shall be retained for a period of twenty years.

Notes

W. Va. Code R. § 64-31-11