La. Admin. Code tit. 46 § XLV-5355

Current through Register Vol. 50, No. 9, September 20, 2024

Section XLV-5355 - Record Keeping [Formerly Section 5347]

A. All midwives shall keep accurate and complete records of all care provided and data gathered for each client.

B. The midwife shall maintain an individual client chart for each woman under her care. The chart shall include results of laboratory tests, observations from each prenatal visit, records of consultations with physicians or other health care providers, and a postpartum report concerning labor, delivery, and condition of the newborn child. The chart shall be made available to the client upon request, and with the client's consent, to any physician or health care provider who is called in as a consultant or to assist in the clients care. This chart shall be kept on standard obstetric forms, or other forms approved by the board. Inactive records shall be maintained no less than 6 years. All records are subject to review by the board.

C. Evidence of the required physician evaluation and examination shall be maintained in the client's records.

D. The attending midwife shall prepare a summary of labor, delivery, and assessment of the newborn, using the Hollister form, or an alternate form containing substantially similar information. One copy of each summary shall be retained with the client's chart and one copy transmitted to the pediatrician or primary care physician.

E. Copies of the disclosure and consent forms required by this Chapter shall be maintained in the clients record.

La. Admin. Code tit. 46, § XLV-5355

Promulgated by the Department of Health and Human Resources, Board of Medical Examiners, LR 12:520 (August 1986), amended by the Department of Health and Hospitals, Board of Medical Examiners, LR 17:779 (August 1991), Amended by the Department of Health, Board of Medical Examiners, LR 421295 (8/1/2016).

AUTHORITY NOTE: Promulgated in accordance with R.S. 37:1270 and 37:3241-3259.