Section R9-16-115. Client and Newborn Records

A.      A midwife shall ensure that a record is established and main- tained according to A.R.S. §§ 12-2291 and 12-2297 for each:

1.        Client, and

2.        Newborn delivered by the midwife from a client.

B.       A midwife shall ensure that a record for each client includes the following:

1.        The client’s full name, date of birth, address, and client number;

2.        Names, addresses, and telephone numbers of the client's spouse or other individuals designated by the client to be contacted in an emergency;

3.        Written  informed  consent   for  midwifery   services,  as required in R9-16-108(C)(2);

4.        Assertion to decline required tests, as required in R9-16- 110(A)(3);

5.        A copy of the emergency care plan, as required in R9-16- 108(E);

6.        The date the midwife began providing midwifery services to the client;

7.        The date the client is expected to deliver the newborn;

8.        The date the newborn was delivered, if applicable;

9.        An initial assessment of the client to:

a.         Determine whether the client has a history of a con- dition or circumstance that would preclude care of the client by the midwife, as specified in R9-16-111; and

b.        Determine the:

i.         Number and outcome of previous pregnancies, and

ii.        Number of previous medical or midwife visits the client has had during the current pregnancy;

10.     Progress notes documenting the midwifery services pro- vided to the client;

11.     For a delivery identified in R9-16-108(B):

a.         Rate of dilation, and

b.        Duration of second stage labor;

12.     Laboratory and diagnostic reports, according to R9-16- 108(I);

13.     Documentation of consultations as required in R9-16- 112, including:

a.         Reason for the consultation,

b.        Name of physician or certified nurse midwife,

c.         Date of consultation,

d.        Time of consultation, and

e.         Recommendation made by the physician or certified nurse midwife;

14.     Written reports received from consultations as required in R9-16-112;

15.     A description of any conditions or circumstances arising during the pregnancy that required the transfer of care;

16.     The name of the physician, certified nurse midwife, or hospital to which the care of the client was transferred, if applicable;

17.     Documentation of medications or vitamins taken by the client;

18.     Documentation of medications or vitamins administered to the client and the physician’s written orders for the medications or vitamins;

19.     The outcome of the pregnancy;

20.     The date the midwife stopped providing midwifery ser- vices to the client; and

21.     Instructions provided to the client before the midwife stopped providing midwifery services to the client.

C.      A  midwife  shall  ensure  that  a  record  for  each  newborn includes the following:

1.        The full name, date of birth, and address of the newborn’s mother;

2.        The newborn’s:

a.         Date of birth,

b.        Gender,

c.         Weight at birth,

d.        Length at birth, and

e.         Apgar scores at 1 minute and 5 minutes after birth;

3.        The newborn’s estimated gestational age at birth;

4.        Progress notes documenting the midwifery services pro- vided to the newborn;

5.        Laboratory and diagnostic reports, as required in R9-16- 108(I);

6.        Documentation of consultations as required in R9-16- 112:

a.         Reason for the consultation,

b.        Name of physician or certified nurse midwife,

c.         Date of consultation,

d.        Time of consultation, and

e.         Recommendation made by the physician or certified nurse midwife;

7.        Written reports received from consultations as required in R9-16-112;

8.        A description of any conditions or circumstances arising during or after the newborn’s birth that required the trans- fer of care;

9.        The name of the physician, certified nurse midwife, or hospital to which the care of the newborn was transferred, if applicable;

10.     Documentation of medications or vitamins taken by the newborn;

11.     Documentation of medications or vitamins administered to the newborn and the physician’s written orders for the medications or vitamins;

12.     Documentation of newborn screening, including when the specimen collection kit, as defined in A.A.C. R9-13- 201, was submitted and results received, as required in R9-16-108(K)(4)(c);

13.     The date the midwife stopped providing midwifery ser- vices to the newborn; and

14.     Instructions provided to the client about the newborn before the midwife stopped providing midwifery services to the newborn.

Historical Note

New Section R9-16-115 renumbered from R9-16-107 and amended by exempt rulemaking at 19 A.A.R. 1805, effective July 1, 2013 (Supp. 13-2).