Introduction to midwifery documentation 2014

Introduction to Midwifery Documentation

Sarah Stewart

Australian College of Midwives

Professional Development Officer

Sarah.stewart@midwives.org.au

http://www.flickr.com/photos/15729248@N00/6994457

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

https://www.flickr.com/photos/evilpeacock/3134153839

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.

• 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 & audithttp://www.flickr.com/photos/8566600@N07/2801690057

• 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

http://www.flickr.com/photos/86530412@N02/8213432552

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

http://www.flickr.com/photos/33055478@N00/2654610149

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?

Rules and Regulations• There are a number of rules, professional

frameworks, standards and laws that guide and direct midwifery documentation

http://www.flickr.com/photos/30231516@N00/399354425

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: http://www.oaic.gov.au/privacy/privacy-act/privacy-law-reform#whatschanged

• Summary of the Australian Privacy Principles: http://www.oaic.gov.au/images/documents/AustralianPrivacyPrinciples_summary.pdf

Activity

• In relation to documentation, how do you define the difference between privacy and confidentiality?

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: http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Codes-Guidelines.aspx

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

Professional

• The Australian College of Midwives is the peak body for midwives: http://www.midwives.org.au

• 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

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.

http://www.flickr.com/photos/7121825@N07/2591900916

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?

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

• 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

http://www.flickr.com/photos/8566600@N07/3098564600

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

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’

http://www.flickr.com/photos/44124365893@N01/91692347

Make sure there is not conflict between two different records eg. timing on CTG trace and notes

Timings recorded consistentlyIf entry is made after event, date, time and

signature should be recordedAbbreviations 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 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

Activity

• Read this birth story: http://loverlyfamily.wordpress.com/2011/02/10/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.

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

2. Abbreviations can never be used. True or FalseFalse – abbreviations can be used as long as

they are first written out in full

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

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

5. True or False. Contemporaneous documentation means documenting at the time something happens.

Answer: True

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

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.

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

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

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

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