(1) Clinical records shall contain information prescribed by rule, including, but not limited to:
(a) Identifying information.
(b) Risk assessments.
(c) Information relating to prenatal visits.
(d) Information relating to the course of labor and intrapartum care.
(e) Information relating to consultation, referral, and transport to a hospital.
(f) Newborn assessment, APGAR score, treatments as required, and followup.
(g) Postpartum followup.
(2) Clinical records shall be immediately available at the birth center:
(a) At the time of admission.
(b) When transfer of care is necessary.
(c) For audit by licensure personnel.
(3) Clinical records shall be kept confidential in accordance with s. 456.057 and exempt from the provisions of s. 119.07(1). A client’s clinical records shall be open to inspection only under the following conditions:
(a) A consent to release information has been signed by the client; or
(b) The review is made by the agency for a licensure survey or complaint investigation.
(4)(a) Clinical records shall be audited periodically, but no less frequently than every 3 months, to evaluate the process and outcome of care.
(b) Statistics on maternal and perinatal morbidity and mortality, maternal risk, consultant referrals, and transfers of care shall be analyzed at least semiannually.
(c) The 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.
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