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:
‘It is important to emphasise at this early stage that unhappily the evidence was, in certain important respects, incomplete. The clinical records of this labour are not full and no records at all appear between 4 a.m. and 10.15 a.m. Each of these might be regarded as critical periods. Unhappily whoever did take over from [the midwife] singularly failed to complete the partogram which is effectively devoid of useful information…’
Decisions about care and treatment are often taken on a multidisciplinary basis. Record entries must include the background to the discussion and its outcome. This will indicate the reason for the decision and corroborate the account of other team members. Records must also corroborate any other legal requirement or form completed by the woman in the midwife's presence. If a woman signs a consent form, that should be recorded and the details discussed should be included. Details of telephone calls made—even if unanswered—to the woman, or to others about the woman, and discussions arising from them with date and time, should be included, as should referrals to specialist practitioners. Where there are particular concerns, these telephone conversations should be confirmed in a letter.
Team members may have differences of opinion regarding the care of a woman. Any expression of dissent a midwife has with another midwife or doctor should be recorded, with the facts leading to the disagreement, the reason for the objection and, crucially, any follow-up action taken.
Views of women and relatives
A further essential entry must be the views of women and their relatives. It is useful to differentiate the views of women and relatives and the midwife's own entry by using quotation marks, e.g. ‘I'm in agony with the pain’. Relatives are an important source of progress or concern (Parliamentary and Health Service Ombudsman, 2013). They know the woman well and may notice changes in her condition more quickly as a result. Their views must be recorded and acted on.
Records must be written legibly
It is essential that all records, instructions, prescriptions or referrals for treatment be written legibly and indelibly. Records are the key communication tool between midwives. They allow for continuity of care. It is essential that record entries can be read and this begins with the clarity of the entry. Clarity requires ink that contrasts with the paper being used for entries. For white paper, use black ink as this gives the greatest contrast and best clarity when copied.
The standard of handwriting is also a requirement of the midwife's duty of care. If care is initiated by a midwife and harm results because others could not read the midwife's handwriting, liability in negligence is likely to arise (Prendergast v Sam and Dee Ltd & others [1989]).
Legibility extends to the signature of the midwife who made the entry. Identifying the people and, therefore, witnesses involved in an incident is crucial if a complaint is made. As well as a signature, the name in print or block capitals and grade of the person writing should be noted at least once in the notes during the course of the record.
Writing with indelible ink or typeface is essential for two reasons. First, the record must stand the test of time. It can be as long as 25 years before it is referred to again, and a faded record is of little value as evidence. In Reynolds v North Tyneside Health Authority [2002] a woman successfully sued for damages cause by a midwife's negligence during her birth some 21 years earlier. Second, the credibility of your record as evidence is enhanced by its being made at the time of the incident. Credibility is essential to the reliability of the record as evidence of what occurred. Using indelible ink or typeface reassures the court that the entry has not been subsequently altered in any way. Midwives must, therefore, avoid using pencil or a computer entry system that does not use a time stamp or some other method to ensure that the entry cannot be altered without a trace. Altering a record is seen as a serious matter and can result in prosecution, dismissal and removal from the register (Griffith, 2013).
Records must be clear and unambiguous
Records are an essential tool in the continuity of care. Care to be implemented and progress made must be clearly stated. The record is also likely to be read by non-midwife and non-medical persons. In Derbyshire CC v SH [2015] a judge criticised the record and report entries of a social worker as overly complex, jargonistic and impossible for the family involved in the case to understand. In response to one entry that read, ‘due to [SH]s’ apparent difficulties identifying the concerns, I asked her to convey a narrative about her observations in respect of [KH]'s and [CK]'s relationship…’ the judge reasonably wondered why the social worker did not just write ‘I asked her to tell me what was wrong’ (Derbyshire CC v SH [2015] at para 39).
Use of jargon and abbreviations
The temptation to use jargon and abbreviations as a form of professional shorthand is compelling for busy, overworked midwifery staff. However, the risk of miscommunication increases dramatically by using this shorthand. Misinterpretation of short-form notes such as abbreviations are a major cause of medication error in midwifery (National Health Service Litigation Authority, 2012).
Records must be accurate
To confirm the chronology of record entries, each entry must be identified with date (day, month and year) and time (using the 24-hour clock) and signed with the midwife's name printed legibly underneath the signature, together with his or her position. Initials for entries must not be used, as it is vital to be able to identify the member of staff if a complaint is made.
Errors
All alterations must be made by scoring out with a single line that does not completely obscure the error. Correcting fluid must not be used. This removes any suggestion of wrongdoing or attempting to cover up an incident. The struck-out error should be followed by the dated, timed and signed correct entry. No blank lines or spaces that could facilitate entries being added at a later date should be left between entries.
The record should demonstrate the chronology of events and of all significant consultations, assessments, observations, decisions, interventions and outcomes. Reports and results should be seen, evaluated and signed by the practitioner before being filed in the patient's records. This is the key to a good record. This is what a lawyer would try to pull apart in order to win a case.
Records must be complete
It is essential that records are complete. If a section of a record is not relevant then a reason for this must be given. If the woman's condition remains the same, say so but be careful of arbitrary ambiguous entries such as ‘slept well, all care given’, that have little meaning.
A midwife received a suspension and 2 year caution from the Nursing and Midwifery Council (NMC) after admitting failing to complete records for a woman in her care. The midwife accepted that she had not recorded observations of maternal or fetal wellbeing during the period the woman was under her care. She also admitted failing to record any physical assessment or whether the woman was in labour.
The midwife did record that she was unable to perform cardiotocography as no machines were available, but admitted she did not follow up this entry and accepted that she could have made efforts to locate a cardiotocograph machine or listen to the fetal heart manually using a sonic aid or Pinard's stethoscope.
The midwife claimed she looked in on the woman every 2 hours but, as this was not documented contemporaneously in the woman's record, there was no evidence to support the claim. An overall assessment of whether the woman was in labour; maternal observations of pain, contractions, temperature, respirations, blood pressure, observations of fetal wellbeing, fetal heart rate and fetal movements; and a plan for the woman's care were all missing from the record (NMC, 2015).
Conclusion
Midwives must be aware that what they write in a woman's record does matter. Records are never neutral—they will either support a midwife's care or condemn the midwife if the record entries are poorly written or fail to show that the midwife has discharged his or her duty of care.