Ohio Administrative Code|Rule 3701-7-15 | Record keeping requirements.

                                                
(A) Medical record. Each maternity unit
		  or newborn care nursery shall maintain a medical record for each patient that
		  documents, in a timely manner and in accordance with acceptable standards of
		  practice, the patient's needs and assessments, and services rendered. Each
		  medical record shall be legible and readily accessible to staff for use in the
		  ordinary course of treatment.
(B) Each maternity unit shall maintain
		  delivery logs that includes the following, if known at the time of
		  delivery:
(1) Maternal
			 name;
(2) Admission
			 date;
(3) Estimated date of
			 confinement;
(4) Membrane rupture date
			 and time;
(5) Type of anesthesia,
			 to include;
(a) Epidural;
(b) General;
(c) Local; or
(d) Spinal;
(6) Type of delivery, to
			 include:
(a) Cesarean section;
(b) Forcep;
(c) Trial of labor after cesarean;
(d) Vaginal; or
(e) Vacuum;
(7) Delivery date and
			 time;
(8) Newborn's
			 weight;
(9) Apgars;
(10) Gestational age;
			 and
(11) Complications, if
			 any, to include:
(a) Delivery and postpartum problems;
(b) Diabetes (gestational);
(c) Emergency cesarean section;
(d) Hemorrhage;
(e) Known fetal anomalies;
(f) Placenta previa;
(g) Placental abruption;
(h) Preeclampsia;
(i) Gestational hypertension; or
(j) Uterine rupture.
(C) A provider may keep the delivery log
		  required by paragraph (B) of this rule on an electronic system that makes the
		  required information readily accessible to the director.
(D) Each maternity unit or newborn care nursery shall not
		  disclose individual medical records except as authorized by the patient, the
		  parent or guardian of an infant or minor, or as allowed by state and federal
		  laws and regulations, including but not limited to the provisions of this
		  chapter of the Administrative Code.
(E) Each maternity unit or newborn care nursery
		  shall:
(1) Systematically review
			 records for conformance with acceptable standards of practice and the
			 requirements of this chapter of the Administrative Code;
(2) Maintain an adequate
			 medical record-keeping system and take appropriate measures to ensure the
			 confidentiality of patient medical records;
(3) Maintain fetal
			 monitoring strips in a format that maintains the record for the period of time
			 required for medical record retention; and
(4) Maintain medical
			 records as necessary to verify the information and reports required by statute
			 or regulation for five years from the date of discharge.
(F) The medical records of the maternal residents of a
		  maternity home shall include, but not be limited to, prenatal history, physical
		  examination, and treatment and medication orders.
(G) The medical records of the infant residents of a
		  maternity home, where applicable, shall include, but not be limited to, a
		  history of gestation, delivery and immediate postnatal periods, physical
		  examinations, and treatment and medication orders.
(H) A maternity home shall keep all records and reports for
		  not less than five years and such records and reports shall be available for
		  inspection by the director.