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Midwifery documentation
 

Midwifery documentation

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Here are a few thoughts about how midwives should think about documentation. I'd be really pleased to hear any other tips you may have

Here are a few thoughts about how midwives should think about documentation. I'd be really pleased to hear any other tips you may have

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    Midwifery documentation Midwifery documentation Presentation Transcript

    • Midwifery Documentation http://www.flickr.com/photos/15729248@N00/6994457
    • 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
    • http://www.flickr.com/photos/44124365893@N01/91692347
    • 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