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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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  • 1. Midwifery Documentation
  • 2. Framework for midwifery documentation in Australia
    • Australian Nursing & Midwifery Council Code of professional conduct
      • Conduct Statements
    • National Competency Standards for the Midwife
  • 3. Why do we document?
    • Record of experience for woman
    • Record of experience for midwife
    • Professional expectation (ACMI)
    • Legal requirement
    • Form of accountability
  • 4.
    • 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
  • 5.
    • 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
  • 6. Inadequate record keeping:
    • Impairs continuity of care
    • Introduces poor communication between staff
    • Creates risk of medication being omitted or duplicated
  • 7.
    • Fails to focus attention on early deviation from the norm
    • Fails to place on record significant observations and conclusions
  • 8. Well kept records should:
    • Be contemporaneous
    • Be legible
    • Have clarity of meaning
    • Show timing and sequence of events accurately
    • Have a distinguishable signature
  • 9. 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’.
  • 10.
    • 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
  • 11.
    • 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
  • 12. 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
  • 13. 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
  • 14. Augmentation with syntocinon
    • Record how you reviewed contractions and fetal heart before increasing dose
    • Write the dose on the CTG trace
  • 15.
    • Record any discussion about pain relief
    • Record “wait and see” decisions
  • 16. 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
  • 17.
  • 18. 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