Midwifery Documentation

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Framework for midwifery documentation in Australia

• Australian Nursing & Midwifery Council Code of professional conduct– Conduct Statements

• National Competency Standards for the Midwife

• http://www.midwives.org.au/scripts/cgiip.exe/WService=MIDW/ccms.r?PageId=10038

Why do we document?

• Record of experience for woman

• Record of experience for midwife

• Professional expectation (ACMI)

• Legal requirement

• Form of accountability

• Knowledge sharing with colleagues/women

• Reflection on practice

• Measurement of practice against standards /quality assurance

• Proof of care given - faded memories and poor records make it difficult to defend

• Women should be encouraged to carry their own notes and write their story in the notes

• Facilitates partnership, gives a voice to the woman and improves the sharing process

Inadequate record keeping:

• Impairs continuity of care

• Introduces poor communication between staff

• Creates risk of medication being omitted or duplicated

• Fails to focus attention on early deviation from the norm

• Fails to place on record significant observations and conclusions

Well kept records should:

• Be contemporaneous

• Be legible

• Have clarity of meaning

• Show timing and sequence of events accurately

• Have a distinguishable signature

Useful tips

• Do not use abbreviations

• Print full name by signature at beginning of notes, with job title

• Delete with single line, with date, time and signature. Do not use ‘whitening’.

• Make sure there is not conflict between two different records eg. timing on CTG trace and notes

• Timings recorded consistently

• If entry is made after event, date, time and signature should be recorded

• Abbreviations should only be used once whole term has been written eg fetal heart (FH).

• Discussions about plan of care should be recorded including risks of treatment

• Careful notes made about what is said if woman refuses treatment

• Woman countersigns to prevent any further dispute eg VBAC at home

Further recommendations

• Response to meconium in liquor. Record colour and amount of liquor ( clear or not). Meconium - thick or thin, fresh or stale - decision made

CTG monitoring

• Name, date, time record on trace.

• Check automatic timings.

• Acknowledge end of trace.

• Acknowledge abnormality with initials to prove m/w was aware of what was happening

• Record ‘wait & see’ decisions on trace.

• Record significant events on trace eg VE

Augmentation with syntocinon

• Record how you reviewed contractions and fetal heart before increasing dose

• Write the dose on the CTG trace

• Record any discussion about pain relief

• Record “wait and see” decisions

Following birth

• Debrief - woman should have a copy of her notes

• Woman to sign notes to confirm the written word is an honest account of what happened

• Write a personal statement after a case that may have repercussions

• Frequently and systematically review your notes, checking for completeness

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References • Mason D & Edwards P. 1993. Litigation: a risk

management guide for midwives. London:RCM• Shepherd, J., Rowan, C., & Powell, E. (2004).

Confirming pregnancy and care of the pregnant woman. In C. Henderson & S. Macdonald (Eds.), Mayes’ Midwifery (pp235-287). London: Bailliere Tindall

• Sinclair, C. (2003). A midwife’s handbook. St Louis, USA: Saunders