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Introduction to midwifery documentation 2014


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Basic information and learning activities about documentation for midwifery students, with a focus on the Australian healthcare context

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Introduction to midwifery documentation 2014

  1. 1. Introduction to Midwifery Documentation Sarah Stewart Australian College of Midwives Professional Development Officer
  2. 2. Aims for this week • To be able to describe why midwives document • To find out what professional and legal frameworks, rules and standards guide midwifery practice in relation to documentation • To be able to discuss the implications of inadequate documentation • To describe key features of well-kept records
  3. 3. Why do we document? • Provides a record of the birthing experience for the woman • Provides a record of experience for midwife • It is a professional expectation • There is a legal requirement for all midwifery care to be recorded Documentation is a key midwifery skill and essential element of midwifery care. Here are some reasons why midwives place so much focus on documentation in every day midwifery practice.
  4. 4. • Allows you to share knowledge with colleagues & women, which is especially important when transferring care to another health professional • Supports you to reflect on your practice • Supports measurement of your practice against standards, as part of quality assurance & audit
  5. 5. • Proof of the care you have given which is especially important in the case of litigation - faded memories and poor records makes it difficult to defend a midwife's position years down the line
  6. 6. Women’s-Held Notes • Women should be encouraged to carry their own notes and write their story in the notes. However, this varies from hospital to hospital, and practice to practice • Sharing documentation with women facilitates partnership between midwife and woman, gives a voice to the woman and improves the sharing process
  7. 7. Activity • What do you think are the issues with women holding their own notes, and how do you think midwives can work to overcome those problems?
  8. 8. Rules and Regulations • There are a number of rules, professional frameworks, standards and laws that guide and direct midwifery documentation
  9. 9. Law • The new Privacy Act came into force in March 2014. It is very important that you are aware of its contents and the implications for you: act/privacy-law-reform#whatschanged • Summary of the Australian Privacy Principles:
  10. 10. Activity • In relation to documentation, how do you define the difference between privacy and confidentiality?
  11. 11. Nursing and Midwifery Board of Australia (NMBA) • The NMBA is the regulatory body that sets out professional rules and regulations that midwives have to abide by: Statements/Codes-Guidelines.aspx
  12. 12. Activity Look at the list of codes, standards and guidelines listed on the NMBA website link on the previous slide. • List which ones deal with documentation • Describe how they impact on midwifery practice
  13. 13. Professional • The Australian College of Midwives is the peak body for midwives: • The ACM National Midwifery Guidelines for Consultation and Referral provide guidance for midwives on how to document when women chooses care outside the guidelines, as well as what to write when referral a woman or baby to other health professionals
  14. 14. Employer • Employers ( eg hospitals, independent midwifery practices, or other health service providers) will have policies and procedures around documentation. It is very important that you know what your employer’s requirements are for documentation.
  15. 15. Activity • The next time you are on clinical placement, check out the policies, procedures and guidelines related to documentation. • What are the key messages about how you should document? • Are there any conflicts between what you see in these policies etc compared to legal and professional rules and regulations? • If so, how will you manage that conflict?
  16. 16. Inadequate documentation Poor documentation can have a number of significant consequences. • It impairs continuity of care eg information about a woman or baby can be missed • Introduces poor communication between health professionals • Creates a risk of medication being omitted or duplicated
  17. 17. • Can prevent health professionals from picking up early deviation from the norm, which can be detrimental to mother or baby • Fails to place on record significant observations and conclusions made by midwives
  18. 18. Well kept records should: • Be contemporaneous ie written at the time of the event • Be legible • Have clarity of meaning • Show timing and sequence of events accurately • Have a distinguishable signature
  19. 19. Useful tips 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’
  20. 20. 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).
  21. 21. Discussions about plan of care should be recorded including risks of treatment and ‘wait and see’ decisions Careful notes made about what is said if woman refuses treatment Woman countersigns to prevent any further dispute eg triplet birth at home Frequently and systematically review your notes, checking for completeness
  22. 22. Activity • Read this birth story: 2/10/our-birth-story • Document the birth as if you were the midwife, Barbara (the story comes from America so the midwife is called a nurse) caring for Erin.
  23. 23. Activity – complete this short quiz 1. Confidentiality means: A. Documentation is not shared with anyone B. Documentation is shared with any health professional C. Documentation is only shared with relevant health professionals D. Documentation is not shared with husband/partner Answer: C
  24. 24. 2. Abbreviations can never be used. True or False False – abbreviations can be used as long as they are first written out in full
  25. 25. 3. Which is the odd one out? The NMBA social media policy says: A. It is permissible to document a woman’s birth story on Facebook B. You may not use any patient information in social media without permission C. Midwives must be aware of their professional responsibilities D. Unprofessional behavior may be in breach of the Code of Conduct Answer: A
  26. 26. 4. The NMBA Competency Standards say: A. Documentation should be brief and legible B. Documentation should be completed at the midwife's convenience C. Documentation should only be hand written D. Documentation should be contemporaneous, comprehensive and logical Answer: D
  27. 27. 5. True or False. Contemporaneous documentation means documenting at the time something happens. Answer: True
  28. 28. 6. Which is correct? When writing in healthcare notes you should: A. Write in red pen when you are concerned about something B. Write your name in full as well as your signature C.Not worry if your signature is illegible because everyone at work knows who you are D. Only enter information on a computer because hand writing can be illegible Answer: B
  29. 29. 7. True or False. It is permissible to change notes at a later date True, but you must cross out the inaccurate words just once, and date and sign your changes so it is transparent what the changes are, and why you have made them.
  30. 30. 8. True or False. You can be taken to court for an action that is not documented. True. Excellent documentation provides evidence about your actions and protects you against litigation
  31. 31. 9. Poor documentation can lead to: A.Inappropriate medication being given B.Difficulties in understanding what care has been provided at the time of staff handover C.Midwives being given writing lessons D.Women being poorly informed about their care Answer: C
  32. 32. 10. Excellent documentation: A.Enables midwives to provide evidence of their decision-making B.Takes up lots of storage space in the hospital administration office C.Explains to women what happened and why during their birthing experience D. Provides full information about a woman’s progress during her birthing journey Answer: B
  33. 33. References • Mason D & Edwards P. 1993. Litigation: a risk management guide for midwives. London: RCM • Pairman et al. 2010. Midwifery. Preparation for practice. Sydney: Elsevier • Sinclair, C. 2003. A midwife’s handbook. St Louis, USA: Saunders