1(1) 2Clinical records shall contain information prescribed by rule, including, but not limited to:
15(a) 16Identifying information.
18(b) 19Risk assessments.
21(c) 22Information relating to prenatal visits.
27(d) 28Information relating to the course of labor and intrapartum care.
38(e) 39Information relating to consultation, referral, and transport to a hospital.
49(f) 50Newborn assessment, APGAR score, treatments as required, and followup.
59(g) 60Postpartum followup.
62(2) 63Clinical records shall be immediately available at the birth center:
73(a) 74At the time of admission.
79(b) 80When transfer of care is necessary.
86(c) 87For audit by licensure personnel.
92(3) 93Clinical records shall be kept confidential in accordance with s. 103456.057104and exempt from the provisions of s. 111119.07(1)112. A client’s clinical records shall be open to inspection only under the following conditions:
127(a) 128A consent to release information has been signed by the client; or
140(b) 141The review is made by the agency for a licensure survey or complaint investigation.
155(4)(a) 156Clinical records shall be audited periodically, but no less frequently than every 3 months, to evaluate the process and outcome of care.
178(b) 179Statistics on maternal and perinatal morbidity and mortality, maternal risk, consultant referrals, and transfers of care shall be analyzed at least semiannually.
201(c) 202The governing body shall examine the results of the record audits and statistical analyses and shall make such reports available for inspection by the public and licensing authorities.
History.-ss. 12, 21, 22, 27, ch. 84-283; s. 33, ch. 87-225; s. 1, ch. 90-3; s. 4, ch. 91-429; s. 195, ch. 96-406; s. 20, ch. 98-166; s. 15, ch. 98-171; s. 10, ch. 2000-160.
