Tag Archives: documentation

Record keeping

IMG_6268 - Version 2

When attending any birth, record keeping is extremely important, both during the birth itself (to facilitate communication) and afterward.

Early this month, I attended a study day organised by IMUK (an organisation of independent midwives in the UK). The day was entitled, “Health Care Records on Trial,” and the purpose was to ensure we are all aware of best practice when it comes to record keeping, as well as some of the pitfalls to avoid ending up in court should all not go to plan. Our host and instructor, Andrew Andrews MBE, was Bond Salon‘s Director of Health & Social Care. And he was fierce! Mr Andrews inspired due diligence through his penetrating glare alone. But the day was far from dreary and fear-mongering, instead offering really clear guidance, based on illustrated examples from Andrews extensive legal experience in health care.

Mr Andrews presentation referred frequently to the NMC’s Principles of good records (2009). While I strive to ensure my records are of the highest possible quality, I am aware I have not always met the highest standard – now even moreso! – but there is always room for improvement. In addition to being a legal duty, maintaining accurate and fit for purpose records helps to ensure safety by facilitating communication between the team.

We were all keen to develop greater understanding about how to document care which falls outside of mainstream guidelines, or when women decline the care on offer. Many women engage an independent midwife when the NHS does not provide the care they have decided is best for them. We discussed in detail the criteria for offering treatment on the NHS (therapeutic effect & reasonable prospect of success) vs private treatment (welfare, well-being & reasonable prospect of success). These subtle differences can make a big difference.

poolside notesMr. Andrews is a big fan of keeping the notes with the woman and documentation by the bedside (or poolside, as I am doing in the picture to the right). The Francis Report indicated that patients should have access to their notes in real time. This ensures that those caring for a woman have immediate access to all relevant information, and she or her loved ones can highlight any errors. Poor record keeping contributes to a discontinuity in care, and this in turn puts patients at risk of harm. Collaborative, bedside record keeping also helps all members of staff to follow the core principles of:

  • Patient’s [sic] autonomy
  • Patient’s right to self-determination
  • Working in partnership with the patient as decision-maker

Care records should be chronological, but not necessarily sequential. In the margin is the time you put pen to paper, in the text is the time you did it. Events should be recorded as close to real time as possible, but must be captured within 24 hours. After 24 hours records are no longer considered ‘contemporaneous.’ No need to use ‘written in retrospect’ at all, and the expression only refers to events recorded after the 24 hour window.

We had a debate about the records also being ‘the woman’s story.’ I have mixed feelings about this. As an independent midwife, I used to give women a copy of their notes and really felt how important this story was to them. However, working in the NHS, where I frequently care for women whose clinical histories I do not already know thoroughly, I often find it tricky to wade through thick narrative notes in order to extract essential information. In my self-designed notes, I used to have three columns: the time I was recording, the clinical highlights, the story. This is my preferred system, combining the best of both purposes. In an NHS context, I may begin to use a continuation sheet for the story, to separate it from clinical information my colleagues may need to know quickly.

Mr Andrews reminded us that the purpose of documentation is to ensure patient safety and continuity of care. They are a reminder of the plan and context of care, and a means of communicating with colleagues. Failure in communication is almost always identified in serious case reviews. Therefore, he recommended records should be:

  • Bullet points
  • Captured in the context of care
  • Written with your colleagues in mind

I am inclined to agree!

You too have an opportunity to be inspired by Mr Andrew’s penetrating glare and brilliant knowledge of health and social care cases, as he will be appearing, along with Sir Robert Francis, QC, at The RCM Legal Birth Conference on Tuesday, 7 July 2015.

– Shawn