Ohio Admin. Code 3701-7-15

Current through all regulations passed and filed through November 4, 2024

Section 3701-7-15 - Record keeping requirements

(A) Medical record. Each maternity unit or newborn care nursery shall maintain a medical record for each patient that documents, in a timely manner and in accordance with acceptable standards of practice, the patient's needs and assessments, and services rendered. Each medical record shall be legible and readily accessible to staff for use in the ordinary course of treatment.

(B) Each maternity unit shall maintain delivery logs that includes the following, if known at the time of delivery:

(1) Maternal name;

(2) Admission date;

(3) Estimated date of confinement;

(4) Membrane rupture date and time;

(5) Type of anesthesia, to include;

(a) Epidural;

(b) General;

(c) Local; or

(d) Spinal;

(6) Type of delivery, to include:

(a) Cesarean section;

(b) Forcep;

(c) Trial of labor after cesarean;

(d) Vaginal; or

(e) Vacuum;

(7) Delivery date and time;

(8) Newborn's weight;

(9) Apgars;

(10) Gestational age; and

(11) Complications, if any, to include:

(a) Delivery and postpartum problems;

(b) Diabetes (gestational);

(c) Emergency cesarean section;

(d) Hemorrhage;

(e) Known fetal anomalies;

(f) Placenta previa;

(g) Placental abruption;

(h) Preeclampsia;

(i) Gestational hypertension; or

(j) Uterine rupture.

(C) A provider may keep the delivery log required by paragraph (B) of this rule on an electronic system that makes the required information readily accessible to the director.

(D) Each maternity unit or newborn care nursery shall not disclose individual medical records except as authorized by the patient, the parent or guardian of an infant or minor, or as allowed by state and federal laws and regulations, including but not limited to the provisions of this chapter of the Administrative Code.

(E) Each maternity unit or newborn care nursery shall:

(1) Systematically review records for conformance with acceptable standards of practice and the requirements of this chapter of the Administrative Code;

(2) Maintain an adequate medical record-keeping system and take appropriate measures to ensure the confidentiality of patient medical records;

(3) Maintain fetal monitoring strips in a format that maintains the record for the period of time required for medical record retention; and

(4) Maintain medical records as necessary to verify the information and reports required by statute or regulation for five years from the date of discharge.

(F) The medical records of the maternal residents of a maternity home shall include, but not be limited to, prenatal history, physical examination, and treatment and medication orders.

(G) The medical records of the infant residents of a maternity home, where applicable, shall include, but not be limited to, a history of gestation, delivery and immediate postnatal periods, physical examinations, and treatment and medication orders.

(H) A maternity home shall keep all records and reports for not less than five years and such records and reports shall be available for inspection by the director.

Replaces: 3701-7-16

Ohio Admin. Code 3701-7-15

Effective: 10/1/2019
Five Year Review (FYR) Dates: 10/01/2024
Promulgated Under: 119.03
Statutory Authority: 3711.12
Rule Amplifies: 3711.05, 3711.12
Prior Effective Dates: 7/15/1976, 4/30/2003, 8/1/2008, 01/01/2012