N.M. Admin. Code § 8.370.17.26

Current through Register Vol. 35, No. 23, December 10, 2024

Section 8.370.17.26 - CLIENT HEALTH RECORD

The facility shall maintain client health records in a legible, uniform, complete and accurate format that provides continuity and documentation of maternal and newborn information which is readily accessible to health care practitioners, while protecting confidentiality, using a system that allows for reliable and safe storage, retrieval and loss prevention. The facility must use a record form appropriate for use by the practitioners in the facility which contains the required information necessary for transfer to an acute care maternal and newborn hospital.

A. Record contents: Each licensed facility must maintain a medical record for each client which may be in a paper or electronic format but which can be easily accessible, copied, provided, reviewed and transported in the event of any emergency or transfer. Every record must be accurate, legible and promptly completed. At a minimum, facility health records for each client must include written documentation of the following:

(1) client demographics;

(2) client consent forms;

(3) pertinent medical, social, family, reproductive and nutritional history;

(4) a list of medications that are currently prescribed for the client, including any self-administered over-the-counter medication or neutraceuticals, including dose of medication, route of administration, and frequency of use;

(5) allergy list;

(6) initial physical exam;

(7) initial and on-going risk assessment and status;

(8) laboratory, radiology and other diagnostic reports;

(9) assessment of the health status and health care needs of the client;

(10) evidence of continuous prenatal care including progress notes;

(11) evidence of prenatal educational resources;

(12) labor and birth summary;

(13) postpartum care with evidence of follow-up within 48 hours of birth;

(14) newborn care and follow-up;

(15) appropriate referral of ineligible clients and documentation of transfer of care;

(16) documentation of any consultations, special examinations and procedures;

(17) discharge summary and applicable instructions to the client;

(18) list of staff present during labor, birth and postpartum;

(19) evidence that client rights have been provided to each client; and

(20) consent form for participation in research signed by the client, if applicable.

B. Client records maintenance:

(1) current client records shall be maintained on-site and stored in an organized, accessible and permanent manner, with copies easily accessible for review, transfers or in an emergency;

(2) the facility shall have in place policies and procedures in compliance with applicable law, for maintaining and ensuring the confidentiality of client records, which include the authorized release of information from the client records; and the retention and transfer of client records at closure or ownership changes;

(3) noncurrent client records shall be maintained by the facility against loss, destruction and unauthorized use for a period of not less than five years from the date of discharge and be readily available within 24 hours of request; if, any other applicable statutes or regulations require a longer term of record retention than five years, the longer term shall apply to the facility.

C. Chart review: At a minimum, a chart review performed by the internal quality committee shall consider written documentation of:

(1) appropriateness of admissions and continuation of services;

(2) complete client demographic information;

(3) signed informed consent(s);

(4) appropriate referral of ineligible clients;

(5) continuous prenatal visits, beginning no later than 32 weeks;

(6) continuous risk assessment throughout prenatal care and for admission in labor;

(7) appropriate maternal and newborn follow-up after birth;

(8) appropriateness of diagnostic and screening procedures;

(9) complete initial history;

(10) complete initial physical exam;

(11) complete prenatal labs and screenings;

(12) appropriateness of medications prescribed, dispensed or administered;

(13) documentation of medical consultation, if indicated;

(14) appropriate identification and management of complications;

(15) appropriate transfer of care for maternal/fetal/newborn indications;

(16) compliance with these rules;

(17) compliance with policies, procedures and clinical practice guidelines for maternal and fetal assessment during labor and postpartum;

(18) compliance with evidence based standards of practice;

(19) effectiveness of staff utilization and training;

(20) completeness of client records;

(21) review of the management of care of individual clients or targeted types of clients or cases for the appropriateness of the clinical judgment of the practitioner(s) in obtaining consultation and managing the case relative to standards of care and policies; and make recommendations for any improvements of care; and

(22) review and analyze outcome data and trends, and client satisfaction survey results.

N.M. Admin. Code § 8.370.17.26

Adopted by New Mexico Register, Volume XXXV, Issue 12, June 25, 2024, eff. 7/1/2024