Essay: Health records/record keeping – midwives

There are many personal attributes that a midwife must aspire to provide, in addition to upholding a high level of professionalism in all aspects of his or her career. Record keeping is just one area of professional duty that is a compulsory requirement to ensure the delivery of outstanding care to the service user. The practise of documenting factual events enables the midwife to create a historical record of when, how and why certain procedures took place, whether consent was obtained or what information was given at the time. By adhering to this collaborative approach, the records can be referred back to for auditing or training purposes, assist others with continuity of care and can even be used in legal proceedings (Nursing and Midwifery Council (NMC), 2009).
This essay will define the meaning of health records and touch on some of the different forms of record keeping that a midwife will encounter during the care of a woman as well as outline the guidelines that surround the documentation process. It will then explore the practise of handwritten records, particularly during the antenatal period of a woman, and provide an insight into their relevance to the role of the midwife and what necessary information they are obliged to include. Finally, before drawing an overall conclusion, it will examine the importance of good record keeping and its’ legal implications.
Health records are an integral part and legal requirement of the midwifery profession that are outlined by the Data Protection Act 1998 as facts and evidence provided and documented by a health professional regarding the well-being of an individual under their care. These records can be legally accessed by the patient who can request to have the contents of which explained to them.
Methods of record keeping are quite varied and may comprise of laboratory reports, monitoring equipment printouts, emails, letters between healthcare professionals, and computerised or handwritten notes. Whatever form they are presented in, they all carry the same level of importance and the same attention to detail should be maintained (NMC, 2009). When completing documentation relating to patient care, midwives should consider the following guidelines; records should be precise, written legibly (if done by hand), must not include irrelevant information or indistinguishable terminology and should be validated with the time, date and signature of the person making the entry. If any errors are made within a hand-written entry, correction fluid should not be used, it should merely be crossed through with a line, and again accompanied by the time, date and signature. Records should be documented as the events happen or as soon as it is practicably possible and if they are written retrospectively this should be accompanied by an explanation. Risks or complications should also be documented and highlighted to identify any further action that may be required either by the midwife or other professionals involved in the care of the patient (Charles, 2013; NMC, 2015; Wildeman and Yearley, 2014).
The large proportion of midwifery documentation is likely to be handwritten within the maternity notes held by the expectant woman, followed by the notes taken during and after the delivery of the baby. For example, maternity notes are provided to the woman on her booking appointment, who will then need to retain these notes throughout her pregnancy and be expected to bring them to each antenatal or medically related appointment (NHS Choices, 2015). It is unlikely that the woman will see only one midwife or other healthcare professional throughout her pregnancy so it is imperative that this document builds up a detailed account of her shared care plan. Within the maternity notes the woman’s personal details along with current and past health issues, including any previous surgical interventions, serious illnesses, and details of any previous pregnancies will be recorded. In addition to this, the details of any screening tests offered, whether accepted or declined, and any information or advice given should also be written into these notes as verification that it has been discussed (Kean, Godfrey, and Sullivan, 2014). Further information provided to the woman, such as antenatal classes, infant feeding, vitamin K and what to expect during labour are just as important to her as the routine checks and should also be noted. By providing these facts it will enable the woman to make informed choices about her care and the care of her baby and will also provide other care givers an insight into what has already been discussed (National Institute for Health and Care Excellence (NICE), 2008).
Dependant on whether the woman is parous or nulliparous and without prior complications, there are usually between seven and ten antenatal appointments throughout the pregnancy that will include routine observations such as blood pressure, urinalysis and measurement of the fundal height (NICE, 2008). The findings of which, will need to be written into her notes to build a record of what is normal and to help identify any deviations from the norm that may potentially signpost the midwife to any anomalies or complications that may be developing for the woman, the fetus or both. Of course, if this is the case, the midwife would need to detail and justify her findings, plan a course of action and ensure continuous evaluation for an ongoing satisfactory level of care. Additionally, the midwife may need to involve other specialist healthcare professionals which may necessitate the use of other methods of record keeping, such as emails, letters and copies of laboratory reports, all of which will need to be documented and held within the woman’s notes (Baston, 2014).
Record keeping carries legal implications as well as providing fundamental information required for care shared between healthcare professionals. Records are proof of observations, discussions, what has been consented to and what clinical care has been delivered to the patient. According to Dimond (2005) midwives, above all other healthcare professionals, are more susceptible to legal challenges and will therefore find their records under potential scrutiny because of lawsuits filed against them. All midwifery related documentation must be held for a period of 25 years with the exception of instances where a child has a mental disability or brain damage, in which case documentation must be retained until the patient’s demise.
Documentation must contain enough detail to demonstrate that the midwife has upheld a duty of care. This even includes the legibility of handwriting to enable others to accurately follow through instructions or provide the correct medications in the right format and/or quantities. Failure to do so may result in harm to or even death of a patient, which then in turn may lead to a claim of negligence. During legal processes, the success of the case is largely based on the evidence provided and not necessarily the truth. The omission of facts can make or break litigations which proves just how detrimental the content of records can be. The midwife must also write clearly so others can read it with ease and must also be mindful of the way in which the content is written so as not to use unnecessary expressions, acronyms or professional jargon that the woman or another care giver may not fully understand. If brought into a court of law, these details could be examined and professional integrity could be questioned causing much embarrassment or may even potentially be a deciding factor that loses the case (Griffith, 2007).
The value of record keeping should never be underestimated and excuses of being too busy to complete them will not stand up in court. Whilst the demands of midwifery in the 21st century are high and may present more complex cases such as obesity, women having babies later in life or other adverse physical challenges, it is easy to see how record keeping can be shunned in favour of hands-on care. However, the fact remains that midwives are accountable for their own actions which includes a satisfactory level of documentation capable of supporting them in court if any legal proceedings were made against them (NMC, 2009; Wildeman and Yearley, 2014).
Further knowledge surrounding record keeping has been obtained by the author, by identifying a range of different documentation methods and the essential components therein. It would appear that irrespective of the mode of documentation relating to patient care, whether it is on paper, held on a computerised system or on a laboratory report, it is the specific content within that is most significant. Patient records need to be sufficiently adequate to provide evidence and facts of what care has been given, how and why it was given, what recommendations and referrals were made along with other details of any discussions that took place. Contrariwise, midwives should refrain from including irrelevant details, using unknown abbreviations and jargon that may be misconstrued by other professionals. There is potential for midwives to be drawn into processes of litigation and their records are a reflection of their professionalism. They are accountable for all of their actions, be it in the physical, verbal or written form so their record keeping must be of an exemplary standard to support this. In conclusion, record keeping is an indispensable part of midwifery that is not to be taken lightly and should be given just as much thought and attention as all other aspects of care provided.
Word Count: 1543
References:
Baston, H. (2014). Antenatal Care. In J. E. Marshall, & M. D. Raynor (Eds.), Myles textbook for midwives. (16th ed.). (pp. 180-181). London: Elsevier Churchill Livingstone.
Charles, C. (2013). Risk management, litigation and complaints. In V. Chapman & C. Charles (Eds.), The midwife’s labour and birth handbook. (3rd ed.). (pp. 359-360). Oxford: Wiley-Blackwell.
Data Protection Act 1998 (c.29). London: TSO.
Dimond, B. (2005). Midwifery records and legal issues. British Journal of Nursing, 14(20), 1076-1078. doi: 10.12968/bjon.2005.14.20.20050
Griffith, R. (2007). Record keeping: midwives and the law. British Journal of Midwifery, 15(5), 303-304. doi: 10.12968/bjom.2007.15.5.23406
Kean, L., Godfrey, A., & Sullivan, A. (2014). Antenatal screening of the mother and fetus. In J. E. Marshall, & M. D. Raynor (Eds.), Myles textbook for midwives. (16th ed.). (pp. 205-206). London: Elsevier Churchill Livingstone.
National Institute for Health and Care Excellence (NICE). (2008). Antenatal care for uncomplicated pregnancies. (CG62). London: NICE.
NHS Choices. (2015). Your antenatal care. NHS. Retrieved November, 13, 2015, from http://www.nhs.uk/conditions/pregnancy-and-baby/pages/antenatal-midwife-care-pregnant.aspx#first
Nursing and Midwifery Council (NMC). (2009). Record keeping – guidance for nurses and midwives. London: NMC.
Nursing and Midwifery Council (NMC). (2015). The code: professional standards of practice and behaviour for nurses and midwives. London: NMC.
Wildeman, C., & Yearley, C. (2014). Effective Documentation. In I. Peate & C. Hamilton (Eds.), The student’s guide to becoming a midwife. (2nd ed.). (pp. 27-28). Oxford: Wiley-Blackwell.