Florida Administrative Code § 59A-11.005

“Requirements for licensure under the Agency for Health Care Administration regulations”

Birthing centers must maintain clinical records for each patient. Each record must contain the following information:

(a) Identifying information including client's name, address and telephone number;

(b) Initial history and physical examination including laboratory findings and dates;

(c) Obstetrical risk assessments and pre-term labor risk assessments including the dates of the assessments;

(d) The dates and topics of the educational sessions attended;

(e) The date and time of the onset of labor;

(f) The course of labor including all pertinent examinations and findings;

g) The exact date and time of birth, the presenting part, the sex of the newborn, the numerical order of birth in the event of more than one newborn, to include filing of the birth certificate, and the Apgar score at one minute and five minutes;

(h) Time of expulsion and condition of placenta;

(i) All treatments rendered to the mother and newborn including prescribing prescriptions, the time, type, and dose of eye prophylaxis;

(j) Copy of the Metobolic screening report;

(k) Condition of the mother and newborn including any complications and action taken;

(l) All medical consultations relevant to the client specifically;

(m) Referrals for medical care and transfers to hospitals including that information germane to the circumstances;

(n) Examinations of the newborn and postpartum mother; and

(o) Instructions given to the client regarding postpartum care, family planning, care of the newborn, arrangements for metabolic testing, immunizations, and follow-up pediatric care.

Related laws:

Florida Statutes § 20.42

Florida Statutes § 383.302

Florida Statutes § 383.307

Florida Statutes § 383.308

Florida Statutes § 383.309

Florida Statutes § 383.315

Florida Statutes § 383.316

Florida Statutes § 383.318

Florida Statutes § 383.32

Florida Statutes § 383.327

Florida Statutes § 383.335