La. Admin. Code tit. 48 § I-9565

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-9565 - Medical Records Requirements

A. The medical record of the mother and newborn shall include, but not be limited to, the following documentation:

1. informed consent signed by the patient and the CNM;

2. demographic and patient information;

3. family, medical, social, reproductive, nutrition and behavioral history;

4. initial maternal assessment and examination;

5. evaluation of maternal/fetal risk factors;

6. written orders for maternal/fetal and newborn care;

7. laboratory and/or diagnostic test results;

8. documentation of maternal/fetal and newborn monitoring;

9. postpartum assessments;

10. physical assessment of newborn, e.g., Apgar score, weights, measurements;

11. labor and discharge summaries; and

12. educational instructions for postpartum and newborn home care, follow ups, and referrals.

La. Admin. Code tit. 48, § I-9565

Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 40:1103 (June 2014).

AUTHORITY NOTE: Promulgated in accordance with R.S. 40:2100-2115.