§ 139.28. Patient medical records.
Patient medical records shall be maintained in accordance with Chapter 115 (relating to medical records services). The following information shall also be included in the neonatal record if the entire maternal records are not maintained as the neonatal records in § 115.23(b) (relating to preservation of medical records):
(1) Obstetrical history of mother’s previous pregnancies.
(2) Description of complications of pregnancy or delivery.
(3) List of complicating maternal disease.
(4) Drugs taken by the mother during pregnancy, labor and delivery.
(5) Duration of ruptured membranes.
(6) Maternal antenatal blood serology, rubella titer, blood typing, Rh factors, and, when indicated, a Coombs test for maternal antibodies.
(7) Complete description of progress of labor including reasons for induction and operative procedures, if any, signed by the attending physician or an authorized delegate.
(8) Anesthesia, analgesia and medications given to mother and infant.
(9) Condition of infant at birth, including the 1-and 5-minute Apgar Score or its equivalent, resuscitation, time of sustained respirations, details of physical abnormalities, pathological states observed and treatments given before transfer to the neonatal care unit.
(10) Abnormalities of the placenta and cord vessels.
(11) Date and hour of birth, birth weight and length, and period of gestation.
(12) A written verification of eye prophylaxis.
(13) Report of initial physical examination, including abnormalities, signed by the attending physician or an authorized delegate.
(14) Discharge physical examination, including head circumference and body length, unless previously done; recommendations; and signature of attending physician or a delegate.
(15) A listing of all diagnoses since birth, including discharge diagnosis.
(16) Specific follow-up plans for care of infant.
Authority The provisions of this § 139.28 issued under section 2102(g) of The Administrative Code of 1929 (71 P. S. § 532(g)); and section 803 of the Health Care Facilities Act (35 P. S. § 448.803).
Source The provisions of this § 139.28 amended through December 3, 1982, effective December 4, 1982, 12 Pa.B. 4129. Immediately preceding text appears at serial page (37911).
Cross References This section cited in 28 Pa. Code § 139.21 (relating to policies and procedures).
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