References

Derbyshire CC v SH. 2015;

Griffith R Extending the scope of wilful neglect will result in paternalistic nursing care. Br J Nurs. 2013; 22:(20)1190-1 https://doi.org/10.12968/bjon.2013.22.20.1190

Griffith R Keeping accurate records. British Journal of Midwifery. 2016; 24:(8)594-5 https://doi.org/10.12968/bjom.2016.24.8.594

Griffith R, Tengnah C, 3rd edn. Exeter: Learning Matters; 2013

London: NHSLA; 2012

Nursing and Midwifery Council. Conduct and Competence Committee Substantive Hearing 11 June 2015. 2015. http://tinyurl.com/h9txyxj (accessed 20 September 2016)

London: The Stationery Office; 2013

Prendergast v Sam and Dee Ltd & others. 1989;

Reynolds v North Tyneside Health Authority. 2002;

S (A Child) v Newcastle & North Tyneside HA. 2001;

Records: What to include

02 October 2016
6 min read
Volume 24 · Issue 10

Maternity records provide an account of the care and treatment given to a woman and baby, allowing progress to be monitored and a clinical history to be developed. Records allow for continuity of care by facilitating treatment and support. They are an integral part of care, and provide evidence of a midwife's involve ment with a woman and baby. Records must, therefore, be sufficiently detailed to show that a midwife has discharged his or her duty of care. To do this, midwives must ensure that their entries adhere to FACTS (Griffith and Tengnah, 2013):

Decisions about care must be included in the midwife's record, including:

Evidence-based care and regular progress reports form the backbone of this detail. An incomplete or inaccurate record can be fatal to a case (Griffith, 2016). In S (A Child) v Newcastle & North Tyneside HA [2001] the judge's annoyance at the incomplete record is clear:

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