Record Keeping for Midwives

Midwives and the need for Good Records

Obstetrics is a highly litigated area of medicine, consequently it is essential that a registered midwife keeps accurate records. Always remember the maxim, of ‘if it is not recorded, it did not happen.’ Allegations of poor or false record keeping feature regularly in the Nursing and Midwifery Council’s fitness to practise hearings as poor record keepings impacts on patient safety.

Clinical RecordsThe Nursing and Midwifery Council’s Guidance on Record Keeping 2010 states; Good record keeping is an integral part of nursing and midwifery practice, and is essential to the provision of safe and effective care. It is not an optional extra to be fitted in if circumstances allow.

Good record keeping has a number of functions:

helping to improve accountability

showing how decisions related to patient care were made

supporting the delivery of services

supporting effective clinical judgements and decisions

supporting patient care and communications

making continuity of care easier

providing documentary evidence of services delivered

promoting better communication and sharing of information between members of the multi-professional healthcare team

helping to identify risks, and enabling early detection of complications

supporting clinical audit, research, allocation of resources and performance planning

helping to address complaints or legal processes

The ‘Code, Professional standards of practice and behaviour for nurses and midwives’ 2015 paragraph 10 states:

10. Keep clear and accurate records relevant to your practice
This includes but is not limited to patient records. It includes all records that are relevant to your scope of practice.

To achieve this, you must:

10.1 complete all records at the time or as soon as possible after an event, recording if the notes are written some time after the event
10.2 identify any risks or problems that have arisen and the steps taken to deal with them, so that colleagues who use the records have all the information they need
10.3 complete all records accurately and without any falsification, taking immediate and appropriate action if you become aware that someone has not kept to these requirements
10.4 attribute any entries you make in any paper or electronic records to yourself, making sure they are clearly written, dated and timed, and do not include unnecessary abbreviations, jargon or speculation
10.5 take all steps to make sure that all records are kept securely, and
10.6 collect, treat and store all data and research findings appropriately.

Although paragraph 10.4 says that records must be clearly written, dated and timed, best practice would be to not only sign your name, but print it as well as it is often difficult for lawyers or tribunals to read or recognise a signature.

Further, it is also good practice not only to date and time a recording but specify the day and time in the 24 hour clock for example, the incident occurred on Wednesday 9th September 2015 at 10.50hrs as mistakes can be made not only about the date but time in the 12 hour clock.

Baby FeetIf you delegate a task, ensure that it is countersigned in the same clear manner as above.
If you wish to make a retrospective record, make sure that it is recorded as ‘made retrospectively’ with the correct date and time it was recorded, again clearly identifying the person making the record.
Midwives routinely talk in jargon. Whilst it is second nature for obstetricians and midwives to refer to abbreviations such as FMF (fetal movement felt) IUGR (Intra uterine growth retardation), PPH (post partum haemorrhage) it is simpler to explain what you are referring to as non- midwives do not understand what the abbreviations mean. Jargon can mean different things to different professions, for example, CPD (cephalopelvic disproportion) may be familiar to midwives but to a lawyer it means continuing professional development! If you must record abbreviations, make a glossary of terms.

Take great care not to record anything that you would not want a patient to see. Under the Data Protection Act 1998 patients can request access to all of their notes. By way of example, some clinicians have been disciplined for making comments such as Fith in the margin, apparently short form for ‘f****d in the head’. Any inflammatory or derogatory comments may lead to difficulties like a referral to the Nursing and Midwifery Council for unprofessional behaviour!

In this technologically minded century, records are increasingly being held in electronic form. The Code provides for electronic record keeping, entries must be attributed to the person making the entry on electronic records just as accurately as paper records.

Always act honestly when making records, don’t make anything up. It is a requirement of the Code that a midwife must act honestly, accurate record keeping forms part of that requirement. The Code also requires a midwife to act ‘immediately’ if she suspects that false records have been made.

Midwives have an extra responsibility in respect of patient records. Under the Nursing and Midwifery Councils’s Midwives Rules and Standards 2012, Rule 6:

Rule 6: Records
(1) A midwife must, as soon as reasonably practicable, ensure that all records relating to the care or advice given to a woman or care given to a baby are, following their discharge from that care:
(a) transferred to the midwife’s employer for safe storage; or
(b) stored safely by the midwife herself if she is self-employed: but if the midwife is unable to do this, transferred to the local supervising authority in respect of her main geographical area of practice for safe storage.
(2) Where a midwife ceases to be registered with the Council, she must, as soon as reasonably practicable, ensure that all records relating to the care or advice given to a woman or care given to a baby are transferred for safe storage to the local supervising authority which was, prior to the cessation of her registration, the midwife’s local supervising authority in respect of her main geographical area of practice.

Midwives standards:
1 All records relating to the care of the woman or baby must be kept securely for 25 years. This includes work diaries if they contain clinical information.
2 Self-employed midwives should ensure women are able to access their records and should inform them of the location of their records if these are transferred to the local supervising authority.

It should be borne in mind that maternity negligence cases can be litigated many years after the birth. Under the Limitation Act 1980, the time for bringing a claim is 3 years after the child reaches maturity, that it is up to the age of 21 years of age. Under the NMC Standards, records have to be retained securely for up to 25 years after birth of a child to cover this limitation period.

For advice on ethical and legal issues concerning record keeping, call Midwives Defence Service in strict confidence.

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