24 Del. Admin. Code § 1795-3.0

Current through Register Vol. 28, No. 5, November 1, 2024

Section 1795-3.0 - Midwifery Record Keeping

3.1 Every midwife shall:

3.1.1 Document completely and accurately the client's history, physical exam, laboratory test results, prenatal visits, consultation reports, referrals, labor and birth care, postpartum care and visits, and neonatal evaluations at the time midwifery services are delivered and when reports are received;

3.1.2 Complete birth and death certificates as required by state law;

3.1.3 Facilitate clients' access to their own records;

3.1.4 Maintain the confidentiality of client records;

3.1.5 Retain records for a minimum of seven years;

3.1.6 Clearly state and document when a woman's choices fall outside the midwife's legal scope of practice or expertise;

3.1.7 Provide infant medical records for newborns either to mother or the infant health care provider.

3.2 Client records must clearly document objective findings, decisions and professional actions, and must contain the following information:

3.2.1 Patient name;

3.2.2 Patient date of birth;

3.2.3 Patient address;

3.2.4 Past pregnancy history, including gravidity, parity, dates, methods of deliver, outcomes, and any complications;

3.2.5 Past medical history, including hypertension, cardiac disease, renal disease, neurological disease, psychiatric illness, diabetes, pulmonary disease, gastrointestinal disease, thyroid or endocrine disorder, gynecologic disease, cancer, hematologic disease, infectious disease, sexually transmitted disease, HIV, musculoskeletal disorder;

3.2.6 Allergies;

3.2.7 Past surgical history including dates, type, outcomes, and any complications;

3.2.8 Social history, including alcohol use, smoking, drug abuse, domestic violence, occupation;

3.2.9 Family history, including medical diseases, genetic disorders, congenital anomalies, multiple gestations;

3.2.10 Physical exam to include vital signs, height, weight, basic exam;

3.2.11 Estimated date of delivery and how calculated;

3.2.12 Number of visits;

3.2.13 Prenatal lab results;

3.2.14 Special test results, such as ultrasound, genetic testing or screening, biophysical profile, and non-stress test;

3.2.15 Maternal complications;

3.2.16 Fetal complications;

3.2.17 Fetal anomalies;

3.2.18 Intrauterine growth restriction, large for gestation, oligohydramnios, polyhydramnios;

3.2.19 Estimated gestational age;

3.2.20 Date and time of birth of infant;

3.2.21 Date and time of delivery of placenta;

3.2.22 Length of each stage of labor;

3.2.23 Date and time of rupture of membranes;

3.2.24 Fetal heart rate during labor;

3.2.25 Documentation of labor progress;

3.2.26 Method of delivery;

3.2.27 Whether the delivery was at home;

3.2.28 Whether transfer to the hospital was necessary and if so, for what reason;

3.2.29 Estimated blood loss;

3.2.30 Administration of any medications;

3.2.31 Intrapartum, delivery, or postpartum complications including but not limited to meconium, shoulder dystocia, hemorrhage, atony, tears or lacerations, arrest disorder, infection, prolapsed cord, bradycardia, fetal distress;

3.2.32 Date and time of birth;

3.2.33 APGAR score;

3.2.34 Gender of infant;

3.2.35 Weight, length, heart rate of infant;

3.2.36 Newborn physical exam and screening;

3.2.37 Medications given, including vitamin K;

3.2.38 Neonatal complications including infection, apnea, bradycardia, hyperbilirubinemia, anomalies, hypoglycemia;

3.2.39 Breastfeeding or not;

3.2.40 Postpartum complications, if any;

3.2.41 Birth control method.

3.3 Every midwife shall have 30 days from the closure of the record or the assembly of a complete record to fulfill a request for medical records.

24 Del. Admin. Code § 1795-3.0

22 DE Reg. 234 (9/1/2018) (Final)