Section 142.504 - Client Records(A) Each birth center shall keep in one centralized location records indicating all the services rendered to birth center clients.(B) Client records in hospital-affiliated birth centers shall be part of the hospital's record system and shall be maintained in conformance with hospital birth center record standards established in written policies and procedures.(C) Each client shall have a single integrated record. Each entry into each client record shall be dated and signed by the staff member making the entry, indicating name and title. Each page of each client's record shall have two unique forms of identification. The record with respect to each client shall be accurate and complete and include the following:(1) Client's name, date of birth, home address and telephone number, and spouse or other person to contact in an emergency.(2) Date of each client visit with birth center staff, at the birth center or elsewhere.(3) Obstetrical and medical history.(4) Diagnostic observations, evaluations, and therapeutic plans.(5) Orders for any medication, test, or treatment.(6) Records of any administration of medications, treatment, or therapy.(7) Laboratory, radiology, and other diagnostic reports.(9) Reports of any consultations, special examinations, or procedures.(10) Referrals to other agencies.(11) Discharge summary where appropriate.(D) Each birth center shall record the following information with respect to each newborn: (1) The condition of the infant at birth to include Apgar Score (or its equivalent) at one minute and five minutes, time of sustained respiration, details of physical abnormalities and pathological states.(2) Date and hour of birth, birth weight and period of gestation.(3) Number of cord vessels and any abnormalities of the placenta.(4) Verification of eye prophylaxis.(6) Treatments, medications and special procedures.(7) Condition at discharge or transfer.(E) Each birth center shall keep each client's record for 20 years after its final treatment of that client.(F) Each birth center shall maintain client records under lock or code and use them in a manner to protect the confidentiality of the information contained therein. Printed copies of electronically stored records shall be disposed of in a manner which assures the confidentiality of client information.(G) Each birth center shall make all client records available promptly to any authorized agent of the Department.Amended by Mass Register Issue 1272, eff. 10/24/2014.