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Licensure recordkeeping requirements – Ohio Admin. Code 3701-7-16

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As a condition of licensure, maternity units and newborn care nurseries must maintain a medical record for each patient for five years that documents the patient’s needs and assessments and services rendered.  The record must include a prenatal history, physical examination and treatment and medication orders.  The medical record of an infant must include a history of gestation, delivery and immediate postnatal periods, physical examinations, and treatment and medication orders.  Records must be maintained as necessary to verify the information and reports required by statute or regulation in an adequate medical record-keeping system.  Appropriate measures must be taken to ensure the confidentiality of patient medical records, and individual records may not be disclosed unless otherwise authorized by the patient, the parent or guardian of an infant or minor, or as allowed by state and federal laws and regulations.  Records will be made available for inspection by the director of health.

Current as of June 2015