Confidentiality, Privacy and Security

Safe Haven

  • 1.  Safe Haven

    Posted 11-24-2020 12:14
    Good morning, everyone.  I noted a posting in 2019 asking for P&P for Safe Haven events  and there was no response.  This is a new topic for me and I would appreciate any feedback on how you managed the record if you've had this type of encounter, any guidance available from your state law, state AHIMA association or from your experience managing other unusual types of encounters.  I've researched this topic and have not found any information, so any feedback may be helpful.  Thank you in advance for your time!

    Sharon Ulrich
    HIM Sr Manager
    Foundation Health Partners

  • 2.  RE: Safe Haven

    Posted 11-25-2020 08:55
    We have a policy and I will copy below.   I cover this in new employee orientation as part of our Safety & Security Program.   We have never had anyone surrender a baby, but I am so happy that we have these laws in place to protect these newborns and give the mother/parents an option.


    The purpose of this policy is to provide the guidelines and procedures to follow when a birth mother/birth parent wishes to relinquish custody of a newborn less than 30 days old.

    Policy Statement:

    It is the policy of Door County Medical Center (DCMC) to provide a safe place for newborns. A Safe Place for Newborns is a program designed to provide a safe place for a newborn baby in lieu of abandonment, injury or death. Wisconsin Statute 48.195 (Amended) allows birth parents to relinquish custody of their newborn infant less than 30 days of age without fear of legal or other retribution provided there has been no intentional maltreatment to the newborn.


    1. Door County Medical Center orients staff and physicians regarding awareness of protocols to follow for the safe place for newborns program.
    2. A medical assessment is to be completed on every newborn placed under the Safe Place law. If the medical assessment reveals intentional injury or maltreatment, the Safe Place for Newborns program will not be utilized and the appropriate authorities will be contacted for investigation. (See Policy "Reporting Cases of Child Abuse and Neglect.")
    3. DCMC offers confidential protective shelter, medical care, and treatment in a hospital setting to babies less than 30 days old. Once the parent/family has left the hospital the baby is under the care of DCMC and cannot be returned to the mother/father or family member should they change their mind and return for the baby. The parent will be instructed to notify the Door County Department of Human Services.
    4. Babies will be accepted by any DCMC employee. Under the State Statute a hospital employee may accept a child that they reasonably believe to be less than 30 days old into their custody if given to them by a birth parent who does not express intent to return for the child.
    5. In accordance with the Wisconsin Statute, no person will induce or coerce a birth parent or person assisting the parent who wishes to remain anonymous into revealing his/her identity, unless the person has reasonable cause to suspect child maltreatment. The parent also needs to be informed of their rights to anonymity.
    6. The birth parents will be provided with an envelope of information that includes the Maternal and Child Health toll-free telephone number and a short prenatal and birth history. Parents will be given the option to complete the form on site or return in the self-addressed, stamped envelope provided. These informational packets will be kept in the Emergency Room, Door County Medical Center Clinic, and both ED and outpatient registration areas.
    7. The amended Wisconsin Statute 48.195 clarifies that a person must file a foundling birth certificate for an infant who is relinquished under the safe haven law in addition to filing a foundling birth certificate for a live born infant of unknown parentage and the state registrar must be notified of the birth certificates filed.
    8. A parent may select any person to assist the parent in the relinquishment of a newborn.
    9. If it is believed that the infant may be Indian the receiving staff member must make every reasonable effort to ascertain whether the child is an Indian child and obtain relevant information as to tribal affiliation of the child and the tribe must be notified.
      Note: By law, Indian parents may not relinquish their rights to their Indian child if the child is under eleven (11) days old.

    The Door County Department of Human Services will be contacted, custody will be transferred within 24 hours and assume responsibility for foster home placement and ultimate permanent placement of an infant taken into the safe place program. If the baby's condition or needs warrants hospitalization, the infant will be admitted to the Medical/Surgical Unit. If admission is not indicated, Door County Department of Human Services will assume responsibility of the infant from the ER Department.


    1. When a mother or any other person approaches hospital/clinic staff and indicates they want the staff member to take the baby into the Safe Place for Newborns Program, the staff member is to accept the baby. A new born may only be relinquished under this chapter by a parent of the newborn. A parent may select any person to assist the parent in the relinquishment of a newborn.
    2. Do not ask the person for their name or any identification.
    3. Ask the person "Do you intend to return for this child?"
    4. Ask the person "Are you giving this child up by your own free will?"
    5. Get the Safe Baby Packet (Attachment A) from the nearest area, (ED and main registration, Emergency Department, all Nursing Units, and Door County Medical Center Clinic).
    6. If child is of Indian descent, obtain tribal information.
    7. Ask the person to anonymously fill out the questionnaire health information while here or mail it back to the hospital in the self-addressed stamped envelope.
    8. Ask the person if a Birth Certificate has been filed.
    9. Emergency Department staff then accepts the infant from the employee if the infant is dropped off in a location other than the Emergency Department. The House Supervisor or a Case Manager/Social Worker will notify the Registration Department.
    10. The baby is to be checked into the hospital under the name of Doe, baby male or female and tracked with a number assigned by Registration.
    11. Notify in-house OB Nurse to complete Newborn Identification with proper name bands and footprints. OB Nurse will also do Birth Certificate (if one is not filed), and infant assessment, including blood glucose levels.
    12. Emergency Room Physician also performs an assessment. If the infant needs admission, consult Pediatrician or Family Practice. Admission will be to the Med/Surg area.
    13. Notify the House Supervisor, who will notify the Administrator on-call.
    14. The Emergency Department staff will call the DCMC Social Worker or Nursing Supervisor if the Safe Baby Program is needed for infant placement. The Hospital Social Worker shall serve as the program coordinator in collaboration with the nursing staff during the hours 0700 to 1630 Monday through Friday. The House Supervisor will serve as the program coordinator after 1630 during the week and on weekends.

    Nancy Davis, MS, RHIA, CHPS
    Director of Compliance & Safety
    Door County Medical Center

  • 3.  RE: Safe Haven

    Posted 11-25-2020 09:52
    Amen to that!

    Posted: 7:51 AM AZ time

    Frank Ruelas
    Compliance Professional

  • 4.  RE: Safe Haven

    Posted 11-27-2020 18:12
    Thank you for sharing your policy, Nancy. It’s my first time to hear about this.

    Susan Oliver, RHIA, CHPS, CPC

    Sent from my iPhone

  • 5.  RE: Safe Haven

    Posted 11-30-2020 17:57

    CAUTION: This email originated from outside of Foundation Health Partners' email system. DO NOT click links or open attachments unless you recognize the sender and know the content is safe.

    Good afternoon, everyone.  Nancy, thank you so much for sharing your policy!  Have you had a situation in which the birth occurred at your facility and then Safe Haven was put into place?  If yes, how did you manage the record(s)?  And, then if the child returns with a new name, after the relinquishment,  there is potential for three records. 


    Thank you for your time and expertise!


    Sharon Ulrich, RHIA

    HIM Sr Manager

    Office:  907-458-5452