Good record keeping is a cornerstone of best practice, and has been emphasised repeatedly by CEMACH and other surveys on patient safety and avoidable harm. They are also NMC and NHSLA CNST requirements.

A report by CEMACH reviewing Diabetes in pregnancy found deficiencies in standards of note-keeping was a common factor associated with poor maternal and fetal outcomes (44% obstetric notes & 51% diabetes notes). The report also highlighted deficiencies in communication between groups of professionals (56%), and between professionals and women (47%)

Therefore it is important to have a comprehensive document which is evidence based and supports care provision. It should clearly record the care provided, and have prompts to alert to risk factors according to the NICE guidelines.

The Diabetes in Pregnancy Notes, have been developed to be used in addition to the Pregnancy Notes, for women who have diabetes either pre-existing or gestational. This ensures the expectant mother is given additional information related to her specific care requirements, whilst ensuring she is still given information on what to expect from other aspects of antenatal care; such as screening tests. These notes aim to facilitate a partnership between the principal stakeholders in antenatal care – mother, baby and the multi disciplinary team engaged in providing care for expectant mothers. The notes place emphasis on patient safety and informed choice.

For further information please contact notes@perinatal.org.uk

Project Team: