A 16-year-old female delivers a stillborn infant in Mercy Hospital. The clinical documentation on the stillborn infant would be filed in which record?

A 16-year-old female delivers a stillborn infant in Mercy Hospital. The clinical documentation on the stillborn infant would be filed in which record?

• A. In newborn's separate record
• B. In mother's record
• C. In infant's file only
• D. In obstetric clinic record

Answer: (B)

When documentation of a delivery outcome is created, it belongs with the patient who received care during the pregnancy and delivery. In the case of a stillbirth, there is no live newborn to create a separate newborn or infant record, so the clinical notes, delivery summary, and fetal outcome are included in the mother’s obstetric/maternity record. This ensures the entire pregnancy and delivery course is documented together for continuity of care, legal accuracy, and follow-up as needed. Some facilities may also have a fetal death certificate linked to the maternal chart, but the primary location for the clinical documentation of the event is the mother’s record, not an infant file or an outpatient obstetric clinic file.

When documentation of a delivery outcome is created, it belongs with the patient who received care during the pregnancy and delivery. In the case of a stillbirth, there is no live newborn to create a separate newborn or infant record, so the clinical notes, delivery summary, and fetal outcome are included in the mother’s obstetric/maternity record. This ensures the entire pregnancy and delivery course is documented together for continuity of care, legal accuracy, and follow-up as needed. Some facilities may also have a fetal death certificate linked to the maternal chart, but the primary location for the clinical documentation of the event is the mother’s record, not an infant file or an outpatient obstetric clinic file.