Basic information and learning activities about documentation for midwifery students, with a focus on the Australian healthcare context

1. 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

2. 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

3. 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.

4. • 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

5. • 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

6. 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

7. 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?

8. 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

9. 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

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

11. 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

12. 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

13. 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

14. 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

15. 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?

16. 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

17. • 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

18. 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

19. 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

20. Make sure there is not conflict between
two different records eg. timing on CTG
trace and notes
Timings recorded consistently
If entry is made after event, date, time and
signature should be recorded
Abbreviations should only be used once
whole term has been written eg fetal heart
(FH).

21. 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

22. Activity
• Read this birth story:
http://loverlyfamily.wordpress.com/2011/0
2/10/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.

23. 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

24. 2. Abbreviations can never be used. True
or False
False – abbreviations can be used as long as
they are first written out in full

25. 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

26. 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

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

28. 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

29. 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.

30. 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

31. 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

32. 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

33. 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