|
Theme
|
% in Notes
|
|
1. Demographic Details – Basic
Advanced
|
16 (94%)
7 (44%)
|
|
2. Significant History -Past
Medical
Obstetric
Family
|
4 (23%)
|
|
3. Specific Risk Factors, Including
special needs
|
8 (47%)
|
|
4. Social/Personal Problems,
e.g. Interpreter required Difficulties
with reading/writing
|
5 (29%)
|
|
5. Detailed Birth History -
Mother and baby
|
13 (76%)
|
|
6. Outline of Discussion Topics,
Including debriefing information re – problems
|
3 (17%)
|
|
7. Information Giving Specific
to:
Ward admission, layout, meals, routine
|
3 (17%)
|
|
8. Blood Tests: Mother - Anti
D etc
Baby - PKU
etc
|
14 (82%)
16 (94%)
|
|
9. Observations, Maternal -
TPR/Uterus/Breasts etc
Baby Skin/Eyes/Cord
etc
|
17 (100%)
14 (82%)
|
|
10. Parent Education - Documentation
on
baby
bathing/top and tailing
|
10 (58%)
|
|
11. Free Text - Pages for actions
and progress reports
|
13 (76%)
|
|
12. Infant Feeding
Breast - Information Giving, BFI Information
plus breast feeding checklist (latching
on, etc)
Bottle - Information giving/ Checklist
(Sterilisation, making up feeds etc)
|
6 (35%)
9 (52%)
|
|
13. Perineal Care
|
7 (41%)
|
|
14. Contraception - documentation
of discussion + choice
|
14 (82%)
|
|
15. Checklist prior to discharge
- Ward to community, leaflet giving
etc
Community discharge
|
9 (52%)
6 (35%)
|
|
16. 6 Week Postnatal Check
Information
|
9 (52%)
|
|
17. Support Groups
|
4 (23%)
|
|
18. Signatures of Health Professionals
|
2 (11%)
|
The postnatal documentation was not standardised
across the region and varied from unit to
unit. The records ranged from a discharge
letter, to a detailed booklet with additional
information in the form of photocopied information
and/or pre-printed leaflets.
