II. Midwifery Record Keeping

 

The Midwife shall:

A.   document completely and accurately the client’s history, physical exam, laboratory test results, prenatal visits, consultation reports, referrals, labor and birth care, postpartum care/visits, and neonatal evaluations at the time Midwifery services are delivered and when reports are received;

B.   facilitate clients’ access to their own records;

C.   maintain the confidentiality of client records;

D.   retain records for a minimum of five years;

E.   complete/file all state required reports/certificates in a timely manner.