Organization and Management for Abortion Facilities - Mo. Code Regs. Ann. tit. 19, § 30-30.060

Missouri law considers abortion facilities ambulatory surgical centers.  However, the state has specific record keeping requirements for abortion facilities that are separate from those of ambulatory surgical centers.  The law requires abortion facilities to maintain a daily list of patients who have abortions services, and are required to keep that list for a period of two years.  In addition, the facility must maintain medical records for each patient.  The medical record must contain a unique identification number, patient identifying information, diagnosis and treatment information, patient consent form, and physician’s orders.  Medical records must be retained for seven years for adults.  For minors, the medical record must be retained for seven years or two years past the time when the minor reaches the age of majority, whichever is longer.  All medical records are the facility’s property, and may be removed from the facility under very limited circumstances.

Additionally, the law requires abortion facilities maintain a quality assurance program.  The quality assurance program must include a review of the following:

1. Completeness of clinical records;
2. Incidence of mortality and morbidity;
3. Surgical complications;
4.  Cases transferred to a hospital;
5. Diagnosis error.

The quality assurance program must provide evidence of steps taken to reduce the incidence of the errors identified.