Records: What to include

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: