Providing high-quality, evidence-based healthcare has always required effective clinical record-keeping. For secure continuity of care, accurate clinical records are crucial. Electronic papers, handwritten notes, voice recordings, emails, consent forms, text messages, lab results, images, videos, and printouts are all included in midwifery records.
It is crucial for a midwife to thoroughly document all interactions with patients and colleagues, diagnoses, and treatment plans. In a variety of situations, such as clinical audits, complaints, a statement for the coroner, disciplinary proceedings, or even a report to help with the management of a clinical negligence claim, practitioners may find themselves relying on the information they have recorded in the medical records. The evidence present in the clinical records is frequently heavily weighted in favor of a doctor’s defense. Claims may need to be settled when they could have been defended if crucial information is missing, deemed insufficient, or erroneous.
Good Record Keeping Tips
- Whether your notes are typed or handwritten, always add the date and your signature.
- Record all choices made, clinical findings, the data provided, the outcomes, consent, and referrals.
- Refrain from including gratuitous or disrespectful remarks in the clinical records. The patient and, in some cases, their relatives may at some point read the documents.
- All treatment refusals and consents must be very carefully recorded in the records.
- If a retrospective entry is made for whatever reason, it must be properly dated with your name and the date the entry was made.
- To maintain continuity of care, all medical records should be well-documented, easily intelligible, concise, and organized. Keep in mind that patients have the right to access their own records, and the right to request that factual inaccuracies or errors be rectified.
- Any medical or legal defense is built on accurate and thorough medical records. You should make keeping accurate medical records a part of your regular routine.
- Remember that patients have a right to see their own records and a right to ask that factual flaws or errors be corrected.
Excellent clinical notes include the patient’s medical background. You are preserving this information for future use by noting all pertinent clinical data. Keep in mind that if you did not record it, it did not occur. This is crucial because it maintains continuity, which is crucial in the case of a contentious medical decision. In the present medical setting, numerous different healthcare experts are involved in the treatment of a single patient, making continuity in clinical notes essential to patient care. Ensuring sure clinical notes are correct, complete, and contain enough information will guarantee that all pertinent healthcare personnel have the right information and will help them with any potential future decisions.
Great interview with a midwife that LOVES archiving midwifery history through record keeping – Importance of Midwifery Record Archiving – YouTube