The purpose of this section is to ensure the birthing center obtains, manages, and uses information to improve patient care and outcomes.
(1) The birthing center must have a defined patient record system, policies and procedures which provide for identification, security, confidentiality, control, retrieval, and preservation of patient care data and information.
(2) The birthing center must maintain a health record for each client and newborn in a legally acceptable document consistent with chapter 70.02 RCW, Medical records—Health care information access and disclosure. Each record must include:
(a) Client's name, birth date, age, and address;
(b) Client's signed informed consent according to WAC 246-329-120(2);
(c) Signed and authenticated notes describing the client and newborn's status during labor, birth, and recovery including, but not limited to:
(i) Risk assessment completed and signed by privileged clinical staff, employed or contracted, before admission ensuring that the client is low-risk. Include the following statement: If the client develops a condition that makes them ineligible for birth center delivery, the privileged clinical staff will not admit the client to the birth center;
(ii) Labor summary;
(iii) Newborn status including Apgar scores and parent-newborn interaction;
(iv) Physical assessment of client and newborn during recovery;
(d) Documentation and authentication of orders by clinical staff and birth center personnel who administer drugs and treatments or make observations and assessments;
(e) Laboratory and diagnostic testing results pertaining to labor and immediate postpartum;
(f) Consultation reports pertaining to labor and immediate postpartum;
(g) Referral, transfer of care, emergency transfer and transport documentation pertaining to labor and immediate postpartum;
(h) Prophylactic treatment of the eyes of the newborn in accordance with WAC 246-100-202 (1)(e);
(i) Intrapartum antibiotics for Group B Strep positive clients per the CDC protocol;
(j) For Hepatitis B positive clients, HBIG and Hepatitis B immunization for newborn;
(k) Refusal of any recommended test or treatment;
(3) All care and treatment entries into the patient record must be completed in a timely fashion.
(4) Entries in the patient record must be typewritten, written legibly in ink or retrievable by electronic means.
(5) For clients managed by a contractor in a birthing center, the licensee must ensure that each patient record of labor, birth, and immediate postpartum is maintained by the birth center and must contain the information as stated in subsection (2)(a) through (k) of this section.
(6) Documentation of orders for medical treatment and medication administered by the provider. Each order must be specific to the patient and must be authenticated, at the time the order is received, by an appropriate health care professional authorized to approve the order or medication.
(7) The licensee must:
(a) Ensure patient records are kept confidential;
(b) Consider patient records property of the birth center; and
(c) Provide a patient access to their patient record under the licensee's policy and procedure and applicable rules.
(8) The licensee must maintain records for:
(a) Adults - Three years following the date of termination of services; and
(b) Minors - Three years after attaining age 18, or five years following discharge, whichever is longer.
(9) The licensee must:
(a) Store records to prevent loss of information and to maintain the integrity of the record and protect against unauthorized use;
(b) Maintain or release records after a patient's death according to chapter 70.02 RCW, Medical records—Health care information access and disclosure; and
(c) After ceasing operation, retain or dispose of records in a confidential manner according to the time frames in this subsection.