MIDIRS Essence > September 2010 > MIDIRS

Dotting our i's and crossing our t's: record-keeping in midwifery

Originally posted on Sept 2010

Midwives’ record-keeping and standards of documentation are increasingly subject to close scrutiny.

This dissection of health care records is supported by stringent legislation, including the Human Rights Act 1998, the Freedom of Information Act 2000 and the Data Protection Act 1998 (Dimond 2003a, Dimond 2003b), all of which have increased the profile of, and access to, health care records.

This has happened within a culture of rising consumer expectations and a willingness (rightly so) to complain about substandard care provision, in the highly litigious areas of midwifery and obstetric practice.

It is a significant fact that poor record-keeping is one of the most common reasons for a health care professional to be removed from the Nursing and Midwifery Council (NMC) register. Poor standards of documentation and record-keeping are likely to lead to individual practitioners and their employing organisations being left vulnerable to criticism and in a position where they are unable to defend themselves, or their actions (Solon 2009, Fraser 2010). This is because all entries documented in the health care records are examined in court, and the law courts take the attitude that if something is not recorded, it did not happen (Dimond 2003b, Wood 2003, Lynch 2009).

As such, it is a fundamental feature of every midwife’s practice for them to maintain their knowledge and awareness of legal requirements and best practice standards through record-keeping and documentation, whether this is in electronic format or paper copy records. This includes maintaining clear and accurate records of the discussions undertaken, clinical assessments, decisions made, and any treatments and/or medication given and their effectiveness (NMC 2008). Records must always be completed contemporaneously, ie as soon as possible after the event has happened, dated and timed, and handwritten entries must be legible and clearly attributable to the practitioner making them and signed, with the persons’ job title printed alongside their initial entry (NMC 2009).

The crucial nature of this aspect of a midwife’s practice has prompted MIDIRS to develop a new learning resource that supports best practice standards and ongoing professional development. This brand new content will be available soon at: www.midirs.org/student

References

• Dimond B (2003a). Freedom of information. British Journal of Midwifery 11(4):233-6.
  
• Dimond B (2003b). Legal aspects of midwifery. 2nd ed. Hale: Books for Midwives Press.
  
• Fraser J (2010). Keeping midwives out of court. Practising Midwife 13(3):36-7.
  
• Lynch J (2009). Health records in court. Abingdon: Radcliffe Publishing..
  
• Nursing and Midwifery Council (2008) The Code: standards of conduct, performance and ethics for nurses and midwives. London: NMC.
  
• Nursing and Midwifery Council (2009). Record keeping: guidance for nurses and midwives. London: NMC.
  
• Solon M (2009). In the dock: threat of litigation. RCM Midwives June/July 2009: 43.
  
• Wood C (2003). The importance of good record-keeping for nurses. Nursing Times 99(2):26-7.

MIDIRS | Photo credit: TheThirdMan - Fotolia.com

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