Section 22-B2621. MEDICAL RECORDS AND REPORTING

 

2621.1Each maternity center shall maintain a medical record system and Practice Guidelines that a provide for identification, security, confidentiality, control, retrieval and preservation of patient care data and information.

 

2621.2Each maternity center shall keep in one centralized location medical records indicating all the services rendered to maternity center patients.

 

2621.3Each patient shall have a single integrated medical record. Each entry into a patient's record shall be dated and signed by the center personnel making the entry, indicating name and title. Each page of each patient's record shall have two unique forms of identification. The record with respect to each patient shall be accurate and complete. Patients shall have access to their own records.

 

2621.4Each maternity center shall record the following information with respect to each newborn infant:

 

(a)All information required by the State Center for Health Statistics of the District of Columbia;

 

(b)The condition of the newborn infant at birth, including the Apgar Score at one minute and five minutes, time of sustained respiration, details of physical abnormalities and pathological states;

 

(c)Footprint and other identification of both the newborn infant and mother;

 

(d)Verification of eye prophylaxis or parental objection;

 

(e)Newborn screening as mandated by District of Columbia law or evidence of parental objection;

 

(f)Treatments, medications and any special procedures or problems utilized or encountered; and

 

(g)Condition at discharge or transfer.

 

2621.5Each maternity center shall keep each patient's and newborn infant's entire record until the infant reaches the age of majority plus three (3) years.

 

2621.6Medical records shall be stored in such a manner as to provide protection from loss, damage or unauthorized access.

 

2621.7A written authorization for release of medical record information outside the maternity center must be signed by the patient prior to the release of any medical record information. In the event of a request for a newborn infant's medical record information, authorization must be signed by the legal parent or guardian except that, if a newborn infant has reached 18 years of age or is otherwise legally emancipated, he or she shall be capable of granting such authorization.

 

2621.8The maternity center shall collect and make available to the State Center for Health Statistics, licensing authorities and other appropriate authorities the following data on an annual basis:

 

(a)Number of births by categories: birth weight, gestational age, maternal age, maternal parity, race, number of prenatal visits and when prenatal care was started;

 

(b)Antepartum, intrapartum and postpartum transfer rates and indications for transfer listed for each transfer;

 

(c)Maternal hospital admissions listed individually;

 

(d)Neonatal hospital admissions listed individually;

 

(e)Stillbirths listed individually;

 

(f)Hospitals which have refused transfers, listed individually with the reason for refusal;

 

(g)Maternal mortality and morbidity and diagnosis; and

 

(h)Perinatal mortality and morbidity and diagnosis.

 

source

Notice of Final Rulemaking published at 46 DCR 2779 (March 19, 1999); as amended by Corrected Notice of Final Rulemaking published at 46 DCR 3970 (April 30, 1999).