OAR 332-025-0110
Records of Care Practice Standards

(1) The LDM must maintain complete and accurate records of each birthing person and newborn.
(2) Records mean written or electronic documentation, including but not limited to:
(a) Midwifery care provided to birthing person and newborn;
(b) Demographic information;
(c) Medical history;
(d) Diagnostic studies and laboratory findings;
(e) Emergency transport plan OAR 332-025-0021 (Risk Assessment Practice Standards);
(f) Informed consent and risk information documentation under OAR 332-025-0120 (Informed Consent Practice Standards);
(g) Health Insurance Portability and Accountability Act (HIPAA) releases;
(h) Documentation of all consultations pursuant to OAR 332-025-0021 (Risk Assessment Practice Standards) (14) through (22) and recommendations regarding indications for consultation from an Oregon licensed health care provider as defined under OAR 332-025-0021 (Risk Assessment Practice Standards)(21), or any other provider specifically identified in OAR 332-025-0021 (Risk Assessment Practice Standards);
(i) Documentation of any declined procedures (OAR 332-025-0022 (Care Practice Standards)(7));
(j) Documentation of termination of care (OAR 332-025-0130 (Practice Standards for Terminating Midwifery Care)); and
(k) Documentation that the birthing person received and signed the patient disclosure form (OAR 332-025-0020 (General Practice Standards)(6)).
(3) Records, including metadata, must be maintained for no less than five years. All records are subject to review by the Office.
(4) All entries must include the LDM’s initials and be legibly written or typed and dated.
(5) Entries made 48 hours after an event must be identified as an addendum or an amended entry and must include the date and time of entry and the LDM’s initials.
(6) All records must include a signature or initial of the LDM.

Source: Rule 332-025-0110 — Records of Care Practice Standards, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=332-025-0110.

Last Updated

Jun. 8, 2021

Rule 332-025-0110’s source at or​.us