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Monday 10:16 CST, April 23, 2018


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Accreditation and Certification

January 10, 2018

New requirements, R3 Report for maternal status assessment, documentation for hospitals, CAHs

R3_reportThree new requirements regarding maternal status assessment and documentation will become effective July 1, 2018, for Joint Commission-accredited hospitals and critical access hospitals that offer obstetric services — specifically labor and delivery. 

These elements of performance (EPs) will be scored in the Provision of Care, Treatment, and Services (PC) chapter, Standard PC.01.02.01 — The [organization] assesses and reassesses its patients.

These new requirements were designed to:

  • Document or assess the current maternal status of infectious diseases, such as human immunodeficiency virus (HIV), hepatitis B, Group B streptococcus (GBS), and/or syphilis.
  • Further promote patient safety and quality of care of the mother and newborn upon arrival and admission to labor and delivery. 
  • Document information in the newborn’s medical record after delivery if the mother tests positive for HIV, hepatitis B, GBS, and/or syphilis. 

The requirements were finalized using responses from public field review, as well as a standards review panel made up of labor and delivery professionals. A R3 Report provides the rationale for the new requirements.

View the prepublication standards, which also will appear in the spring E-dition® for hospitals and critical access hospitals, as well as the 2018 Update 1 publication of the Comprehensive Accreditation Manual for Hospitals. (Contact: Kathy Clark,

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