Okla. Admin. Code § 310:550-7-1

Current through Vol. 42, No. 7, December 16, 2024

Section 310:550-7-1 - Hospital records

(a)Newborn screening blood test results.

(1) The hospital is responsible for implementing a procedure to ensure that a newborn screening blood specimen has been collected on every newborn and transported to the Newborn Screening Laboratory within twenty-four (24) to forty-eight (48) hours of collection. If more than one newborn screen is collected on an infant, each copy of the newborn screen kit should be placed in the infant's medical record. Specimens should be transported in the manner designated by the Department and/or receiving laboratory.

(2) The hospital shall immediately notify the infant's physician, parent(s) or guardian(s), and Newborn Screening Program Coordinator if an infant is discharged without a sample having been collected. These notifications shall be documented in the infant's hospital record.

(3) If test results are not received by the hospital within fifteen (15) days after the date of collection, the hospital shall contact the Newborn Screening Laboratory to verify that a specimen was received. If a specimen was not received, the hospital shall notify the physician.

(4) Any hospital or any other laboratory that collects,handles or forwards newborn screening blood specimens shall keep a log containing the name and date of birth of the infant, name of the ordering physician, name of infant's provider, medical record number, serial number of the Newborn Screening Form Kit, date of specimen collection, date specimen was sent to the certified laboratory, date that test results were transmitted or received and the test results.

(b)Pulse oximetry screening results.

(1)Record of results.

(A) All pulse oximetry screening results shall be recorded in the infant's medical record and the results reported to a parent(s) or guardian(s) prior to discharge from the hospital.

(B) All pulse oximetry screening results shall be recorded on the Newborn Screening Form Kit, along with the infant's name, date of birth, submitting facility, mother's name, and the infant's physician.

(C) If the newborn is not screened for CCHD prior to the Newborn Screening Form Kit being forwarded to the Newborn Screening Laboratory for testing, CCHD screen results shall be communicated to the Newborn Screening Program Coordinator utilizing the Pulse Oximetry Screening Result Form provided by the Program.

(D) The Pulse Oximetry Screening Result Form must be completed in its entirety.

(2)Abnormal pulse oximetry screen results.

(A) It is the responsibility of the authorized health care provider who conducted the pulse oximetry screening to communicate abnormal results to the attending physician or attending clinician immediately.

(B) The newborn shall be evaluated immediately by an attending physician in order to complete the recommended protocol.

(C) The newborn may not be discharged from care until:

(i) A cause for the abnormal pulse oximetry screen has been determined;

(ii) An echocardiogram has been performed, read, and determined not to indicate CCHD; and/or

(iii) A plan of care and follow-up has been established with the newborn's parent(s) or guardian(s).

(D) The birthing facility shall report pulse oximetry screening results to the Department as specified in this Chapter.

(E) It is the responsibility of the birthing facility to notify the newborn's parent(s) or guardian(s), the physician or clinician following the newborn in the hospital, and the infant's physician of abnormal pulse oximetry results.

(3)Newborns not screened for CCHD.

(A) If a newborn is not screened for CCHD secondary to discharge before 12 hours of life, the birthing facility shall:

(i) Follow-up with the parent(s) or guardian(s) to schedule screening of the newborn at the birthing facility between twenty-four (24) and forty-eight (48) hours of life; or

(ii) Follow-up with the parent(s) or guardian(s) to schedule referral of the newborn to an authorized facility for screening between twenty-four (24) and forty-eight (48) hours of life; and

(iii) Report screening results to the Department utilizing the Pulse Oximetry Screening Result Form provided by the Program, and indicating the reason for not screening which may be "early discharge".

(B) If pulse oximetry screening is not indicated for the newborn, the birthing facility shall report the reason for not screening, which may be "screening not indicated due to," and provide other CCHD findings for the newborn to the Department utilizing the Pulse Oximetry Screening Result Form provided by the Program.

(C) If the newborn is not screened for CCHD because of parent or guardian refusal, the birthing facility shall send the Newborn Screening Program Refusal Form to the Department utilizing the form provided by the Program and indicate the reason for not screening, which may be "parent refusal".

Okla. Admin. Code § 310:550-7-1

Amended at 8 Ok Reg 3115, eff 7-12-91 (emergency); Amended at 9 Ok Reg 1475, eff 5-1-92; Amended at 12 Ok Reg 41, eff 10-5-94 (emergency); Amended at 12 Ok Reg 1685, eff 6-12-95; Amended at 15 Ok Reg 121, eff 10-15-97 (emergency); Amended at 15 Ok Reg 1979, eff 5-26-98; Amended at 21 Ok Reg 1286, eff 5-27-04; Amended at 22 Ok Reg 392, eff 12-21-04 (emergency); Amended at 22 Ok Reg 794, eff 5-12-05; Amended at 25 Ok Reg 1153, eff 5-25-08

Amended by Oklahoma Register, Volume 31, Issue 24, September 2, 2014, eff. 9/12/2014

Amended by Oklahoma Register, Volume 40, Issue 23, August 15, 2023, eff. 9/11/2023