Record Keeping Guidance (476)

Objectives

The aim of this guideline is to provide a reference point for all maternity staff, outlining their responsibilities in relation to the documentation of care provided. Record keeping is an essential part of midwifery practice and maternity care. It is a vital element of safe and effective care. All midwives should already be familiar with the NMC guidance on record keeping within the code. (NMC, The Code, 2015) Local Health board guidance is developed with the NMC code at its center. 

Scope

This guidance is written for the benefit of all staff involved in caring for pregnant women and new parents as we all have a responsibility to document any care given; this includes obstetricians, maternity care assistants and other members of the maternity multi-disciplinary team. The focus in this guidance is midwives as they are the main care givers within maternity services.

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The key elements of the current NMC Code (2015) that relate to record keeping are:

  • Respect, support and document a person’s right to accept or refuse care and treatment
  • Make sure that you get properly informed consent and document it before carrying out any action
  • Make sure that people are informed about how and why information is used and shared by those who will be providing care
  • Share necessary information with other health and care professionals and agencies only when the interests of patient safety and public protection override the need for confidentiality
  • Share with people, their families and their carers, as far as the law allows, the information they want or need to know about their health, care and ongoing treatment sensitively and in a way they can understand
  • Maintain effective communication with colleagues
  • Share information to identify and reduce risk

Keep clear and accurate records relevant to your practice:

 This applies to the records that are relevant to your scope of practice. It includes but is not limited to patient records. To achieve this, you must:

  • Complete records at the time or as soon as possible after an event, recording if the notes are written sometime after the event
  • Identify any risks or problems that have arisen and the steps taken to deal with them, so that colleagues who use the records have all the information they need
  • Complete records accurately and without any falsification, taking immediate and appropriate action if you become aware that someone has not kept to these requirements
  • Attribute any entries you make in any paper or electronic records to yourself, making sure they are clearly written, dated and timed, and do not include unnecessary abbreviations, jargon or speculation
  • Take all steps to make sure that records are kept securely
  • Treat and store all data and research findings appropriately (NMC, 2015)

The Royal College of Midwives (2019) states –“Record keeping is a fundamental aspect of midwifery care. The maternity record is unique as a multidisciplinary record, carried by the woman during her pregnancy, where she is given a new pregnancy record for each pregnancy. Information in this record will also form the basis for the newborn’s record when they are born. Digital records not only form part of the women’s medical records, but also facilitate sharing of information between health professionals and with the pregnant woman. Clear, accurate and accessible maternity records support local safety procedures such as the risk governance process by making important aspects of maternity care easily available for review. Digital maternity records additionally have a secondary purpose enabling the collection of data which is used for national mandatory reporting and local audits. Digital records can therefore be seen as a key element of improving quality and safety in maternity care” It is clear that record keeping by all Maternity staff is at the forefront of safe, efficient patient care and should be viewed as of critical importance.

Roles & responsibilities

All midwives, midwifery students, maternity care assistants, healthcare support staff, medical staff and anyone else providing clinical care or guidance to women should:

  • Adhere to the NMC/GMC code and the elements that relate to record keeping;
  • Understand the importance of effective record keeping as a key element of safe and effective care
  • Maintain consistent, complete, clear, accurate, secure, and timely records, to ensure an account of all care given is available for review by the woman and by all professionals involved in care,
  • Effectively and responsibly use a range of digital and other technologies to access, record, share and apply data within teams and between agencies
  • Keep and store securely, effective records for all aspects of the continuum of care for the woman, newborn infant, partner and family,
  • Present and share verbal, digital and written reports with individuals and/or groups, respecting confidentiality. (NMC, 2019)

Guideline

The NMC Code of Professional Conduct guides nursing and midwifery care and as such documentation is at the center of safe clinical practice.

  • All staff should keep clear, accurate and concise records relevant to care provided,
  • Telephone and virtual consultations are an episode of care and should be as fully recorded as in person care,
  • Document at the time or as soon as possible following care, if an emergent situation has occurred,
  • Ensure retrospective entries are adjusted to the assessment date and time to ensure chronological order is achieved, but clearly state what the reason for retrospect is, i.e. clinical emergency type,
  • Attribute entries you make, regardless of medium, to yourself, making sure not to include abbreviations, jargon or speculation,
  • Take all steps to make sure that records are secure and confidential
  • Staff should, at a minimum, carry out the following checks when documenting: right record, right person, right place, right date and time, right details and right login i.e. you are logged in under your own name
  • Staff are responsible for all documentation made under their login, therefore those details should never be shared
  • Student midwives, MCA’s and HCSW’s should complete their own documentation, midwives should be aware how to countersign student entries on the system,
  • If an error or problem is recognised within or when accessing records electronically, the midwife or MCA/HCSW accessing the record is responsible for escalation to appropriate personnel, such as the Badgernet digital midwife to have the record amended
  • When unable to complete records remotely, professionals may need to update the record in an offline setting. It is then their responsibility to ensure the record synchronises with the online version, when able to connect again, prior to the end of the shift/on-call requirement,
  • Midwives should be aware that the digital records allow for multiple users to be documenting in unison, therefore information will update in real time,
  • Midwives should use appropriate technology to document in a woman’s records regardless of place of care i.e., at the bedside or in her home, to maintain contemporaneous documentation whilst including the woman in their care plans,
  • Midwives should be aware of where other members of the multi-disciplinary team are documenting if not using Badgernet i.e., emergency department, imaging departments etc., and should ensure that they access any information about previous history and treatment to inform the current care episode
  • Midwives should ensure that appropriate information is shared with those professionals involved in a woman or family’s care in a way that respects the individual’s right to privacy while prioritizing patient safety. These communications will include other disciplines outside the maternity team including the public protection team, health visitors and GPs and other agencies including social work.
  • When staff are unable to access electronic records due to emergency, downtime or non-registered individuals, all paper records should be scanned and uploaded to the electronic records for completeness, once the electronic system is back on line
  • Midwives should be aware of documentation that is automatically available to the woman when she accesses her records via the Badgernet app. Midwives should ensure that any sensitive information or safeguarding issues are placed in the appropriate area within the records for them to be made available to women when appropriate.

Editorial Information

Last reviewed: 03/05/2024

Next review date: 31/05/2028

Author(s): Mairi McDermid.

Version: 2

Co-Author(s): Christine Cree.

Approved By: Maternity Governance Group

Document Id: 476