OAR 332-025-0110: Records of Care Practice Standards

(1) The LDM must maintain complete and accurate records of each birthing person and newborn. (2) Records mean written or electronic documentation, including but not limited to: (a) Midwifery care provided to birthing person and newborn; (b) Demographic information; (c) Medical history; (d) Diagnostic studies and laboratory findings; (e) Emergency transport plan OAR 332-025-0021; (f) Informed consent and risk information documentation under OAR 332-025-0120; (g) Health Insurance Portability and Accountability Act (HIPAA) releases; (h) Documentation of all consultations pursuant to OAR 332-025-0021 (14) through (22) and recommendations regarding indications for consultation from an Oregon licensed health care provider as defined under OAR 332-025-0021(21), or any other provider specifically identified in OAR 332-025-0021; (i) Documentation of any declined procedures (OAR 332-025-0022(7)); (j) Documentation of termination of care (OAR 332-025-0130); and (k) Documentation that the birthing person received and signed the patient disclosure form (OAR 332-025-0020(6)). (3) Records, including metadata, must be maintained for no less than five years. All records are subject to review by the Office. (4) All entries must include the LDM’s initials and be legibly written or typed and dated. (5) Entries made 48 hours after an event must be identified as an addendum or an amended entry and must include the date and time of entry and the LDM’s initials. (6) All records must include a signature or initial of the LDM.