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

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Midwifery documentation

  1. 1. Midwifery Documentation http://www.flickr.com/photos/15729248@N00/6994457
  2. 2. Framework for midwifery documentation in Australia <ul><li>Australian Nursing & Midwifery Council Code of professional conduct </li></ul><ul><ul><li>Conduct Statements </li></ul></ul><ul><li>National Competency Standards for the Midwife </li></ul><ul><li>http://www.midwives.org.au/scripts/cgiip.exe/WService=MIDW/ccms.r?PageId=10038 </li></ul>
  3. 3. Why do we document? <ul><li>Record of experience for woman </li></ul><ul><li>Record of experience for midwife </li></ul><ul><li>Professional expectation (ACMI) </li></ul><ul><li>Legal requirement </li></ul><ul><li>Form of accountability </li></ul>
  4. 4. <ul><li>Knowledge sharing with colleagues/women </li></ul><ul><li>Reflection on practice </li></ul><ul><li>Measurement of practice against standards /quality assurance </li></ul><ul><li>Proof of care given - faded memories and poor records make it difficult to defend </li></ul>
  5. 5. <ul><li>Women should be encouraged to carry their own notes and write their story in the notes </li></ul><ul><li>Facilitates partnership, gives a voice to the woman and improves the sharing process </li></ul>
  6. 6. Inadequate record keeping: <ul><li>Impairs continuity of care </li></ul><ul><li>Introduces poor communication between staff </li></ul><ul><li>Creates risk of medication being omitted or duplicated </li></ul>
  7. 7. <ul><li>Fails to focus attention on early deviation from the norm </li></ul><ul><li>Fails to place on record significant observations and conclusions </li></ul>
  8. 8. Well kept records should: <ul><li>Be contemporaneous </li></ul><ul><li>Be legible </li></ul><ul><li>Have clarity of meaning </li></ul><ul><li>Show timing and sequence of events accurately </li></ul><ul><li>Have a distinguishable signature </li></ul>
  9. 9. Useful tips <ul><li>Do not use abbreviations </li></ul><ul><li>Print full name by signature at beginning of notes, with job title </li></ul><ul><li>Delete with single line, with date, time and signature. Do not use ‘whitening’. </li></ul>
  10. 10. <ul><li>Make sure there is not conflict between two different records eg. timing on CTG trace and notes </li></ul><ul><li>Timings recorded consistently </li></ul><ul><li>If entry is made after event, date, time and signature should be recorded </li></ul>
  11. 11. <ul><li>Abbreviations should only be used once whole term has been written eg fetal heart (FH). </li></ul><ul><li>Discussions about plan of care should be recorded including risks of treatment </li></ul><ul><li>Careful notes made about what is said if woman refuses treatment </li></ul><ul><li>Woman countersigns to prevent any further dispute eg VBAC at home </li></ul>
  12. 12. Further recommendations <ul><li>Response to meconium in liquor. Record colour and amount of liquor ( clear or not). Meconium - thick or thin, fresh or stale - decision made </li></ul>
  13. 13. CTG monitoring <ul><li>Name, date, time record on trace. </li></ul><ul><li>Check automatic timings. </li></ul><ul><li>Acknowledge end of trace. </li></ul><ul><li>Acknowledge abnormality with initials to prove m/w was aware of what was happening </li></ul><ul><li>Record ‘wait & see’ decisions on trace. </li></ul><ul><li>Record significant events on trace eg VE </li></ul>
  14. 14. Augmentation with syntocinon <ul><li>Record how you reviewed contractions and fetal heart before increasing dose </li></ul><ul><li>Write the dose on the CTG trace </li></ul>
  15. 15. <ul><li>Record any discussion about pain relief </li></ul><ul><li>Record “wait and see” decisions </li></ul>
  16. 16. Following birth <ul><li>Debrief - woman should have a copy of her notes </li></ul><ul><li>Woman to sign notes to confirm the written word is an honest account of what happened </li></ul><ul><li>Write a personal statement after a case that may have repercussions </li></ul><ul><li>Frequently and systematically review your notes, checking for completeness </li></ul>
  17. 17. http://www.flickr.com/photos/44124365893@N01/91692347
  18. 18. References <ul><li>Mason D & Edwards P. 1993. Litigation: a risk management guide for midwives. London:RCM </li></ul><ul><li>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 </li></ul><ul><li>Sinclair, C. (2003). A midwife’s handbook . St Louis, USA: Saunders </li></ul>