Maternity Notes Exemplars

 
 
 
 
 
 
 

The Perinatal Institute has completed a set of booklets to complement the use of maternity notes that we produce to support good quality record keeping and aid supervision. Good record keeping is an integral part of midwifery practice, and is essential to the provision of safe and effective care.

Nursing and Midwifery Council – Record keeping. Guidance for Nurses and Midwives April 2010 www.nmc-uk.org/publications/guidance

National audits have demonstrated that poor record keeping is associated with poor obstetric outcomes. Good record keeping has many important functions such as:

  • Help improve accountability.
  • Demonstrating how decisions related to patient care were made.
  • Supporting the delivery of services and documented evidence.
  • Supporting effective clinical judgements and decisions.
  • Supporting patient care and communications.
  • Making continuity of care easier.
  • Promoting better communication and sharing of information between the members of the multi professional healthcare team.
  • Helping to identify risks, and enabling early detection of complications.
  • Supporting clinical audit, research, allocation of resources and performance planning.
  • Helping to address complaints or legal processes.

Principles of good record keeping

  • Handwriting should be legible and all entries should be signed.
  • In line with local policy, you should put the date and time on all records. This should be in real time and chronological order, and be as close to the actual time as possible. You should not falsify records.
  • Your records should be accurate and recorded in such a way that the meaning is clear.
  • Records should identify any risks or problems that have arisen and show the action taken to deal with them.
  • You have a duty to communicate fully and effectively with your colleagues, ensuring that they have all the information they need about the people in your care. This should also include details of information given about care and treatment.
  • Records should identify any risks or problems that have arisen and show the action taken to deal with them.
  • You must not alter or destroy any records without being authorised to do so.
  • In the unlikely event that you need to alter your own or another healthcare professional’s record, you must give your name and job title, and sign and date the original documentation. You should make sure that the alterations you make, and the original record, is clear and auditable.
  • Where appropriate, the person in your care, or their carer, should be involved in the record keeping process.

View the exemplars:

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