MATERNITY RECORD KEEPING INCLUDING CLINICAL GUIDELINES

DOCUMENTATION IN HANDHELD RECORDS Register no: 06036

Status: Public

Developed in Response to: Intrapartum NICE Guidelines

CNST Best Practice
Contributes to CQC Regulation 9, 12

Consulted With Individual/Body Date

Anita Rao/ Alison Clinical Director for Women’s and Children’s Directorate February 2016
Cuthbertson
Alison Cuthbertson Head of Midwifery / Nursing
Madhu Joshi Consultant for Obstetrics and Gynaecology
Liz Stewart Public Information Manager
Ros Bullen Bell Acting Lead Midwife Community, Named Midwife Safeguarding, PDM
Paula Hollis Lead Midwife Acute Inpatient Services
Chris Berner Lead Midwife Clinical Governance
Sarah Moon Specialist Midwife for Guidelines and Audit
Angela Wrobel Senior Midwife, WJC Braintree
Sarah Dunn Senior Midwife, Postnatal Ward
Angela Woolfenden Senior Midwife, St Peters
Jo Gowers Senior Midwife, Antenatal Clinic
Denise Gray Senior Midwife, Antenatal Day Assessment Ward
Professionally Approved By
Miss Rao Lead Consultant for Obstetrics and Gynaecology February 2016

Version Number 4.0

Issuing Directorate Women’s and Children’s
Ratified By DRAG Chairmans Action
Ratified On 28 April 2016
Trust Executive Sign Off Date May 2016
Implementation Date 10 May 2016
Next Review Date March 2019
Author/Contact for Information Sarah Moon, Specialist Midwife for Guidelines and Audit
Policy to be followed by (target staff) Midwives, Obstetricians, Maternity Support Workers
Distribution Method Intranet & Website. Notified on Staff Focus
Related Trust Policies (to be read in 08086 Clinical Record Keeping Policy
conjunction with) 05098 Maternity Risk Management Policy
04085 Patients Records on Wards Policy
07011 Confidentiality Policy
09062 Mandatory training policy for Maternity Services
Document History
Version No Reviewed by Active Date
1.0 Anne Smith February 2009
2.0 Victoria Dennett April 2012
2.1 Equality and diversity; audit and monitoring sections January 2010
2.2 Clarification to appendix A February 2010
3.0 Sarah Moon October 2012
3.1 Sarah Moon – clarification to Appendix A November 2012
3.2 Sarah Moon – clarification to 13.0 January 2013
3.3 Sarah Moon – clarification to point 7.6 May 2013
3.4 Sarah Moon – clarification to point 7.6 June 2013
3.5 Sara Smith – clarification to point 11.1 and 12.2 July 2013
3.6 Gemma May – clarification to point 11.1, 12.2 and Appendix B June 2014
4.0 Sarah Moon 10 May 2016

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INDEX

1. Purpose

2. Equality and Diversity

3. Scope of the Guideline

4. Background

5. Initialising Maternity Records

6. Handheld records

7. Style and Content

8. Confidentiality and Sourcing Notes

9. Structure of Medical Records

10. Alert Sticker

11. Staff and Training

12. Supervisor of Midwives

13. Audit and Monitoring

14. Guideline Management

15. Communication

16. References

17. Appendices

Appendix A – Filing Arrangements

Appendix B – Record Keeping Audit Tool

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1.0 Purpose

1.1 This guideline is to enable staff to be aware of the process for initialising, accessing and storing
maternity records during the full maternity episode.

1.2 The support staff in achieving high standards in maternity documentation.

2.0 Equality and Diversity

2.1 Mid Essex Hospital Services NHS Trust is committed to the provision of a service that is fair,
accessible and meets the needs of all individuals.

3.0 Scope of the Guideline

3.1 The ‘Guideline for maternity record keeping including documentation in handheld records’ is
a specialist document (register number 04085) and will be in addition to the current trust
policies entitled ‘Clinical record keeping standards’ (register number 08086) and ‘Patients
records on wards policy’ (register number 04085) and the ‘Confidentiality Policy’ (register
number 07011). This guideline should be read in conjunction with these policies.
.
4.0 Background

4.1 The Department of Health Code of Practice for Records Management requires that maternity
records will be retained for a minimum period of 25 years. Maternity records must be easily
retrievable from whatever format or location they are stored in.

4.2 Maternity records are designed to be multidisciplinary and all professionals who see the woman
during her maternity care should be encouraged to use the single set of records. This is to
ensure that there is a complete and contemporaneous record of all the care the patient receives
and that a full and accurate picture is provided to all care givers.

4.3 It is expected that Allied Health Professionals write directly into the maternity record when
seeing a patient as an inpatient. If care then continues on an outpatient basis, regular reports
should be filed in the record particularly if there is a change in treatment, or on discharge.

4.4 All staff must comply with the Clinical Record Keeping Policy; register number 08086.

5.0 Initialising Maternity Records

5.1 This process is to be followed when it is known a woman wishes to have her baby at Mid Essex
Hospital Services NHS Trust:

5.2 A booking letter confirming the pregnancy will be sent to the Maternity Secretaries’ Office from
either a patient self-referral, the general practitioner or the community midwife.

5.3 The Administration Clerk will check to see if the woman has had previous care with the Trust
and has an established hospital number or lilac folder. This relates to any care and not just
previous maternity care.

5.4 If the patient has previous medical/maternity records, those records will be requested and this
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 hospital number will be used for the current pregnancy. It may be necessary for these records
to be regenerated from microfilm or the digitally stored image.

5.5 If the patient has never had any previous care with the Trust, a lilac folder with a hospital
number will need to be generated. This applies irrespective of whether the patient intends
to have a hospital or home birth.

5.6 The lilac folder will remain in the Antenatal Clinic at Broomfield Hospital or either of the two
Midwife-led Units (MLU’s) based at St Peter’s, Maldon; and WJC, located at St Michael’s
Community Hospital, Braintree where there is 24 hour access. The lilac folder will retain basic
demographic information, alert information and any details which cannot immediately be
married up with the handheld records. This includes any documentation from maternity
services contact episode when the patient forgets to bring her handheld records with her.

5.7 Arrangements must be made to link up the documentation with the handheld records
(from any previous maternity episode) as soon as possible following discharge to ensure all
Information pertaining to the current pregnancy is available to the multidisciplinary team.

5.8 When the midwife books the woman for maternity care, she will prepare a set of handheld
Antenatal Care Records which will remain with the patient throughout her pregnancy.

5.9 At the first antenatal booking the midwife will complete a risk assessment as to whether the
patient has a ‘high’ or ‘low’ risk pregnancy and will arrange an appointment with a consultant
obstetrician, if required.

5.10 The name of the lead professional will be allocated at this time and will be reviewed and
amended at each contact as this may change at different times throughout the pregnancy.
It should be made clear in the patient’s health care records who the lead professional is as
the patient may move between low and high-risk care during her pregnancy, labour and
puerperium

6.0 Handheld Records

6.1 Handheld records are produced in three booklets as follows:

• Antenatal Care Record

• Postnatal Care Record – Maternal
• Postnatal Care Record – Baby

6.2 Antenatal Care Record contains the current and past medical/surgical history, health and
family support assessment, anaesthetic assessment, antenatal appointments, antenatal
clinical assessments and individual care plans and antenatal inpatient records.

6.3 Pregnant patients will hold their own ‘Antenatal Care Record’ for the duration of their pregnancy.

6.4 The midwife should ensure that the patient’s name, hospital number and NHS number are
recorded on the front of each complete set of healthcare records

6.5 It is very rare for a patient to lose her handheld records. If this does happen, staff should be
alert to any possible wider issues relating to her personal circumstances. A continuation sheet
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 must be used for recording the relevant information but cannot be entered into the handheld
records. Furthermore, this continuation sheet must be kept within the lilac folder. All
continuation/ additional sheets must contain the patient’s name, hospital number and NHS
number recorded on the front sheet only.

6.6 On admission, in labour, these records will become part of the lilac folder and will be retained
by the maternity staff. If a patient is admitted in labour and has not brought her handheld
records with her, her partner should be asked to either to return home to collect the records or
have someone else to bring them in. In the meantime, a continuation sheet should be used and
then filed securely as per order of filing schedule in the handheld records when available.
(Refer to Appendix A)

6.7 New handheld records should only be generated in exceptional circumstances and only after it
has been confirmed that the originals are irretrievable. These will be designated as duplicate
records.

6.8 The ‘Labour and Delivery Care Record’ must not go home with the mother following delivery.
Once the mother has gone home, the Labour Care Record will then go to the maternity
administration office, Broomfield Hospital to be coded. Once the ‘Postnatal Care Record –
Maternal’ and the ‘Postnatal Care Record – Baby’ has been returned from the community/
MLU’s they will be coded; both ‘Labour and Delivery Care Record’ and ‘Postnatal Care
Record’ will be reunited and then returned to the Medical Records Library at Broomfield
Hospital.
.
6.9 The standard for the order of filing must be met for any loose documentation within any of
the healthcare records before it is secured in the document wallet within the lilac folder. The
purpose of this is to minimise the risk of lost documentation and incomplete records.
(Refer to Appendix A)

6.10 The ‘Postnatal Care Record – Maternal’ and the ‘Postnatal Care Record – Baby’ will be
commenced immediately after delivery and will go home with the mother and baby for the
duration of her postnatal care (if the patient is in area; refer to point 6.13). The community
midwife will retain these records once the mother and baby are discharged to the care of
the Health Visitor.

6.11 The Community Midwife will then return these postnatal records to the Broomfield Maternity
administration office, known as the Maternity Library within 2 weeks at which time they will
be coded.

6.12 After coding the ‘Labour and Delivery Care Record’ and ‘Postnatal Care Records’ are
secured in the lilac folder and returned to the Medical Records Library at Broomfield
Hospital.

6.13 Neonatal notes are retained by the Neonatal Unit prior to discharge home. These notes
are then sent for coding and then forwarded to the Phoenix Satellite Library, at
Broomfield Hospital.

6.14 For those patients who live out of area the Labour Care Record and Postnatal Care
Record should be retained on discharge home to the community midwife. A copy of the
patient’s labour summary should be placed in the discharge letter informing the
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 community midwife.

7.0 Style and Content

7.1 Style - date, time and sign each new entry and record your name, signature and
designation on page 2 of each care record in black ink. All entries should be neat, legible
and use objective, precise language and avoid subjective 'casual' remarks and
abbreviations that might not be understood.

7.2 The responsible midwife or professional reviewing a CTG trace should ensure that they
date, sign and print their surname on each occasion.

7.3 Discharge and clinical letters for outpatients’ attendance (i.e. ones that will be sent from the
hospital to other health care staff) should be timely, neat and accurate.

7.2 Content - remember to record all information regarding current and future care; record relevant
conversations with the family or friends of the patient; record the details of the information give
to patients at the time of discharge. The health professional should ensure that where verbal
consent is required for procedures that this documented in the patient’s healthcare records.
(Refer to the guideline for ‘Clinical record keeping standards’; register number 08086)
(Refer to Appendix B)

7.3 Data Quality - the patient's hospital number is always the patient's primary identifier and must
be recorded on the front page of each care record booklet. In addition, the patient’s name
i.e. first name followed by the surname, and the patient’s NHS number which is a unique
identified should also be recorded in same manner. For any additional pages required refer
to point 6.4.

7.4 Retrospective entries - records should always be written contemporaneously or as soon as

possible after the events described. One of the greatest problems in midwifery is the fact
that a midwife may be under pressure during a delivery and could also be care providing for
more than one patient when in the hospital setting. This makes it impossible for her to
record events at the same time as the delivery takes place; in this situation the health
professional is required, prior to her documentation of events to identify this entry as ‘written
in retrospect’.

7.5 There is no fixed time limit on retrospective writing but best practice as the Nursing
Midwifery Council (NMC) advises is to record as soon as possible after the event has
occurred, ensuring that the date and time of retrospective entries are recorded.

7.6 The records should be completed accurately and without falsification, taking immediate and
appropriate action if you become aware that someone has not kept to theses requirements.

7.7 As a midwife, if you delegate record keeping to pre-registration students of nursing or

midwifery, you must ensure that they are adequately supervised and that they are
competent to perform the task. You must clearly countersign any such entry and remember
that you are professionally accountable for the consequences of such an entry.

7.8 Errors - draw a single line through incorrect entries; initial the error; add today's date; make
6
 a note in the margin that the entry was made in error and note what the correct entry should be;
never erase or use white-out liquid.

7.9 Other Printed Records - printed test results are part of the patient record and should be
filed at the back of the antenatal care record booklet

7.10 Consent Forms - record any information you have given to the patient before they have made
the decision to sign any consent form; this helps ensure that you have gained informed consent;
consent forms are signed by the patient after the treatment has been discussed with the doctor;
If there is clinical photography planned during surgery, include this on the consent form prior to
signing.

8.0 Confidentiality and Sourcing Notes

8.1 Do not remove case notes from the hospital or send original records to other hospitals. The
Medical Records Tracking System on PAS must be used to track the location of the notes
e.g. when case notes are taken from one area of the hospital to another.as per the Trust’s
Casenote Tracking Policy

8.2 Refer to the Trust’s Confidentiality Policy (register number 07011) for detailed information
about the need for confidentiality and compliance with the data protection and Caldicott
Principles.

8.3. All staff to be familiar with the Information Governance Handbook.

9.0 Structure of Medical Records

9.1 It is the responsibility of all staff using maternity records to understand the structure and filing
system.
(Refer to Appendix A)

9.2 All items in this case note folder must be filed in accordance with these guidelines. There should
be no loose papers, every user must leave the folder with the contents secured by the binding
system. Filing will be routinely audited.

9.3 Records of previous pregnancies, for in area women will be filed in a plastic wallet and located
behind the current pregnancy episode.

10.0 Alert Stickers

10.1 An alert sticker is the only sticker that may be placed on the front cover of a set of maternity
records. It should highlight anything that would need to be known by the next clinical member of
staff to be involved with the care of the patient. If an alert sticker is used then it is the
responsibility of the person making the decision, to input the reason for the ‘alert’ on the inside
front cover of the records. This must happen even with the older buff folders that do not have
a specific printed box.

10.2 An alert sticker can be used to denote the following though this list is not exhaustive:

• Drug allergies
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 • Anaesthetic allergies/problems
• Any adverse reaction
• The presence of a do not resuscitate order (order to be filed in correspondence)
• Hearing or visual impairments
• Language issues
• Fetal loss (tear drop sticker)
• Another member of the family with the same name/initials
• A same gender twin
• Any medical records elements that are known to be permanently missing (only medical
records staff will record these)

11.0 Staffing and Training

11.1 All midwifery and obstetric staff must attend yearly mandatory training which includes
record keeping update.
(Refer to ‘Mandatory training policy for Maternity Services (incorporating training needs
analysis. Register number 09062)

11.2 All midwifery and obstetric staff are to ensure that their knowledge and skills are
up-to-date in order to complete their portfolio for appraisal.

12.0 Supervisor of Midwives

12.1 The supervision of midwives is a statutory responsibility that provides a mechanism for
support and guidance to every midwife practising in the UK. The purpose of
supervision is to protect women and babies, while supporting midwives to be fit for
practice'. This role is carried out on our behalf by local supervising authorities. Advice
should be sought from the supervisors of midwives who are experienced practising
midwives who have undertaken further education in order to supervise midwifery services. A
24 hour on call rota operates to ensure that a Supervisor of Midwives is available to advise
and support midwives and women in their care choices.

12.2 Record keeping audits will be undertaken by staff as part of annual supervisory reviews. As
a minimum 2 record keeping audit tools should be completed on an annual basis and
discussed as part of the annual supervisory review.
(Refer to Appendix B)

13.0 Audit and Monitoring

.
13.1 Audit of compliance with this guideline will be considered on an annual audit basis in
accordance with the Clinical Audit Strategy and Policy (register number 08076), the
Corporate Clinical Audit and Quality Improvement Project Plan and the Maternity annual
audit work plan; to encompass national and local audit and clinical governance identifying
key harm themes. The Women’s and Children’s Clinical Audit Group will identify a lead for
the audit.

13.2 As a minimum the following specific requirements will be monitored:

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 • Basic record-keeping standards against which the health records must be audited for
all healthcare professionals
• Basic clinical note keeping standards against which the health records must be audited
for all healthcare professionals
• Storage arrangements for:
i. cardiotocographs
ii. anaesthetic records, including epidural records
iii. fetal blood sampling results/reports
iv. cord pH results/reports
v. securing results/reports relating to previous pregnancies
vi. antenatal screening and ultrasound results

• Arrangements for documenting the name of the lead professional (to include the process
for recording any changes to the lead professional)
• Process for ensuring a contemporaneous complete record of care
• Frequency of audit of health records
• Process for audit, multidisciplinary review of audit results and subsequent monitoring of
action plans.

13.3 A review of a suitable sample of health records of patients to include the minimum
requirements as highlighted in point 13.2 will be audited. A minimum compliance 75% is
required for each requirement. Where concerns are identified more frequent audit will be
undertaken

13.4 The findings of the audit will be reported to and approved by the Multi-disciplinary Risk
Management Group (MRMG) and an action plan with named leads and timescales will be
developed to address any identified deficiencies. Performance against the action plan will be
monitored by this group at subsequent meetings.

13.5 The audit report will be reported to the monthly Directorate Governance
Meeting (DGM) and significant concerns relating to compliance will be entered on the local
Risk Assurance Framework.

13.6 Key findings and learning points from the audit will be submitted to the Clinical Governance
Group within the integrated learning report.

13.7 Key findings and learning points will be disseminated to relevant staff.

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14.0 Guideline Management

14.1 As an integral part of the knowledge, skills framework, staff are appraised annually to
ensure competency in computer skills and the ability to access the current approved
guidelines via the Trust’s intranet site.

14.2 Quarterly memos are sent to line managers to disseminate to their staff the most currently
approved guidelines available via the intranet and clinical guideline folders, located in
each designated clinical area.

14.3 Guideline monitors have been nominated to each clinical area to ensure a system
whereby obsolete guidelines are archived and newly approved guidelines are now
downloaded from the intranet and filed appropriately in the guideline folders. ‘Spot
checks’ are performed on all clinical guidelines quarterly.

14.4 Quarterly Clinical Practices group meetings are held to discuss ‘guidelines’. During this
meeting the practice development midwife can highlight any areas for further training;
possibly involving ‘workshops’ or to be included in future ‘skills and drills’ mandatory
training sessions.

15.0 Communication

15.1 A quarterly ‘maternity newsletter’ is issued and available to all staff including an update on
the latest ‘guidelines’ information such as a list of newly approved guidelines for staff to
acknowledge and familiarize themselves with and practice accordingly.

15.2 Approved guidelines are published monthly in the Trust’s Focus Magazine that is sent via
email to all staff.

15.3 Approved guidelines will be disseminated to appropriate staff quarterly via email.

15.4 Regular memos are posted on the guideline notice boards in each clinical area to notify staff
of the latest revised guidelines and how to access guidelines via the intranet or clinical
guideline folders.

16.0 References

Nursing and Midwifery Council (2015) The Code – Professional standards of practice and
behaviour for nurses and midwives. NMC: March.

Clinical Negligence Scheme for Trusts (2009) Maternity Clinical Risk Assessment Standards
CNST.

DoH Code of Practice for Record keeping including Schedule D – the Retention and
Destruction Schedule

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 Appendix A

Mid Essex Hospital Services NHS Trust

Women’s and Children’s Directorate

Filing for Maternity Records

The list below details the order of filing for current Maternity Care Records and lilac folders:

Antenatal Care Situated at the front of the lilac

Record notes
Antenatal screening Behind Antenatal Care Record Filed chronologically and secured
in the behind the Antenatal Care
Record
Patient information (As appropriate) Behind Antenatal Care Record / Filed chronologically and secured
leaflet proforma or within the care records in the behind the Antenatal Care
Record
Neonatal alert form (As appropriate) Behind Antenatal Care Record Filed chronologically and secured
in the behind the Antenatal Care
Record
Proforma for (As appropriate) Behind Antenatal Care Record Secured behind the Antenatal
Management of Care Record
Multiple Pregnancy
and Birth
Raised BMI Care (As appropriate) Behind Antenatal Care Record Secured behind the Antenatal
record pathway Care Record
Risk Assessment for (As appropriate) Behind Antenatal Care Record Secured behind the Antenatal
Equipment Needed Care Record
for Patient with
Raised BMI
Proforma
Ultrasound reports Behind Antenatal Care Record Filed chronologically and secured
in the behind the Antenatal Care
Record
CTG Small envelope with CTG Record the name, hospital Secured the A4 CTG storage
number, patient name, number, EDD, sequence of envelope on the behind the
hospital number and date. order, reason for CTG, outcome Antenatal Care Record
Insert small brown and signature on the front of the
envelope into A4 CTG A4 CTG storage envelope
storage envelope
Handover of care (As appropriate) Behind Antenatal Care Record Filed chronologically and secured
proforma (Antenatal) in the behind the Antenatal Care
Record
Maternal transfer (As appropriate) Behind Antenatal Care Record Filed chronologically and secured
proforma in the behind the Antenatal Care
Record
In utero transfer (As appropriate) Behind Antenatal Care Record Filed chronologically and secured
proforma in the behind the Antenatal Care
Record
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Labour CDC In front of the Labour Care Filed chronologically and secured
computer print out Record in front of the Labour Care Record

Labour and Situated behind the Antenatal

Delivery Care episode
Record

Drug chart Behind Labour Care Record Secured behind the Labour Care
Record
MEOWS chart Behind Labour Care Record Secured behind the Labour Care
Record
HII form (As appropriate) Behind Labour Care Record Secured behind the Labour Care
Record
Epidural Record and (As appropriate) Behind Labour Care Record Secured behind the Labour Care
observations chart Record
Shoulder dystocia (As appropriate) Behind Labour Care Record Secured behind the Labour Care
proforma Record
Postpartum (As appropriate) Behind Labour Care Record Secured behind the Labour Care
haemorrhage Record
proforma
Fetal Blood FBS results should be Secure the small brown Chronological within the
Sampling (FBS) placed in a small brown envelope chronogically in the documented Labour Care Record
results envelope Labour Care Record

Cord pH results Cord pH results results Secure the small brown Secured behind the Labour Care
should be placed in a small envelope on the Birth Record
brown envelope Assessment page
(As appropriate)
Urinalysis results Secure chronogically in the
appropriate Care Record

Operative Delivery (As appropriate) Behind the Labour Care Record Secured behind the Labour Care
and Theatre Care Record
Record
Anaesthetic records (As appropriate) Integral to the Operative Secured behind the Labour Care
Delivery and Theatre Care Record
Record
Consent form (As appropriate) Behind the Operative Delivery Secured behind the Operative
and Theatre Care Record Delivery and Theatre Care Record

VTE Assessment Behind the Operative Delivery Secured behind the Operative
form and Theatre Care Record Delivery and Theatre Care Record

Operative theatre (As appropriate) Behind the Operative Delivery Secured behind the Operative
times and Theatre Care Record Delivery and Theatre Care Record

Baby Delivery Behind the Operative Delivery Secured behind the Operative
Record and Theatre Care Record Delivery and Theatre Care Record

Handover sheet (As appropriate) Behind the Operative Delivery Secured behind the Operative
from NNU admission and Theatre Care Record Delivery and Theatre Care Record

Handover of care (As appropriate) Behind the Labour Care Record Secured in the behind the Labour
proforma (postnatal) Care Record
Postnatal discharge 1 copy required In front of the Postnatal Care Secured in front of the Postnatal
CDC Record - Maternal Care Record - Maternal

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Postnatal Care Behind the Labour Care Record Secured in the behind the Labour
Record – Maternal Care Record

Specialist referrals (As appropriate) Behind the Postnatal Care Secured in the behind the
Record - Maternal Postnatal Care Record - Maternal
Behind the Postnatal Care Secured in the behind the
Postnatal Care Record - Maternal Postnatal Care Record - Maternal
Record – Baby

Baby drug chart, (As appropriate) File chronologically: baby drug Secured in the behind the
observation and chart, observation and feeding Postnatal Care Record –Baby
feeding charts, charts, referral forms,
referral forms, immunisation forms
immunisation forms
Newborn screening Behind the Postnatal Care Secured in the behind the
forms Record - Baby Postnatal Care Record –Baby

Clear Folder (Retained in the lilac folder Clear folder should be located
inserted behind pregnancy behind pregnancy episode
episode) chronologically
Mat Ad 1 (Self/ Insert in to the clear plastic Secure in the main health record
Midwife/GP referral) wallet file folder (lilac folder)

Antenatal booking Insert in to the clear plastic Secure in the main health record
CDC wallet file folder (lilac folder)

GP referral letters Insert in to the clear plastic Secure in the main health record
wallet file folder (lilac folder)

FAQ Insert in to the clear plastic Secure in the main health record
wallet file folder (lilac folder)

Telephone message Insert in to the clear plastic Secure in the main health record
proforma wallet file folder (lilac folder)

Yellow Alert Forms Insert in to the clear plastic Secure in the main health record
wallet file folder (lilac folder)

Early pregnancy (As appropriate) Insert in to the clear plastic Secure in the main health record
assessment clinic wallet file folder (lilac folder)

Previous Securing results/reports Insert in to the clear plastic Secure in the main health record
pregnancies relating to previous wallet file folder (lilac folder) filed behind the
current pregnancy episode

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 Appendix B

Women’s and Children’s Directorate

Maternity Services

Record Keeping Audit Tool

Audit Date __________________

Hospital Number __________________
Auditor __________________

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 Revised April 2014

Antenatal
NB; all the questions follow in relation to the Hand held notes.
Please circle your responses.
1 Has the lead professional been identified Yes No N/A
2 If the lead professional has changed has this been identified Yes No
3 Is there evidence of information and discussion regarding place of Yes No
birth options
4 Is there documented evidence that social circumstances have been Yes No
discussed
5 Is there documented evidence that Domestic Violence has been Yes No
discussed
6 Has the ethnic origin been documented Yes No
7 Has the woman’s medical history been discussed Yes No
8 Have risk factors been identified, i.e. medical conditions, Yes No
anaesthetic factors, previous pregnancy factors, lifestyle factors, if
so is there documented evidence that the appropriated referral has
been made
9 Is there documented evidence that family history has been Yes No
discussed
10 Is there evidence that Allergies have been identified Yes No

11 If a current mental health problem, or risk has been identified, is Yes No N/A
there documented evidence that this has been communicated to,
Mental health services, GP’s, Health Visitors, Interpretations
services where appropriate
12 When mental health issues have been identified, has a plan been Yes No N/A
made, and potential problems in Postnatal period been
acknowledged
13 Has previous obstetric history been recorded Yes No N/A

14 Is there documented evidence that written information has been

given and discussed regarding;
1. Screening tests , inc; Downs, U/Scan, Blood tests, Including Yes No
consent obtained (NHS Screening leaflet)
2. Place of birth options Yes No
3. Vitamin K Prophylaxis Yes No
4. Fetal Monitoring in labour Yes No
If the woman has declined initial screening, is there evidence of
another offer of screening Yes No N/A
15
15 Is there documented evidence if appropriate that written
information has been given and discussed regarding;
1. Induction of labour Yes No N/A
2. General anaesthetic Yes No N/A
3. Vaginal birth following Caesarean Section Yes No N/A
4. Perineal repair Yes No N/A
5. External Cephalic Version Yes No N/A
6. Women who decline blood and blood products Yes No N/A
16 Are all blood results recorded appropriately Yes No

17 Has the BMI been calculated and documented Yes No

18 For women with BMI above 30, macrosomic baby>4.5kg, first Yes No N/A
degree relative with diabetes, family origin with a high prevalence
of diabetes (south Asian, Black Caribbean)and Middle Eastern has
there been a referral for GTT
19 For women who have abnormal GTT has care been provided in the Yes No N/A
joint clinic
20 For women with BMI >25 Was there a consultant referral Yes No N/A

21 For women with BMI >40 Was there an Anaesthetic referral – with Yes No N/A
a plan for labour and delivery
22 For women with BMI >40 during 3rd trimester – has individual Yes No N/A
assessment been undertake re Manual handling, tissue viability
and Del Suite special persons form completed
23 Was the booking history completed by 12 weeks gestation Yes No

24 If the referral was received after 12 weeks, was the booking history Yes No N/A
completed within 2 weeks of referral being received
25 Is there any documented evidence of an individual plan of Yes No
pregnancy care
26 For women who have had a previous caesarean birth, is there
documented evidence of a discussion regarding the following;
1. Mode of delivery Yes No N/A
2. Place of delivery Yes No N/A
3. Individual plan for delivery Yes No N/A
4. Plan for labour should this commence early Yes No N/A
5. Plan for monitoring fetal heart in labour Yes No N/A
27 If breech presentation has been identified 36/52, is there evidence Yes No N/A
of discussion regarding ECV
28 Has the Infant Feeding Antenatal Check been completed
1. At Booking Yes No
2. 28 weeks Yes No
3. 34 weeks Yes No
29 If labour had not commenced by 40 weeks, is there documented Yes No N/A
evidence that IOL has been discussed

16
30 If Labour had not commenced by 40 weeks, has a membrane
sweep been offered at 41 weeks for;
1. Primips Yes No N/A
2. Multips Yes No N/A
31 If this is a multiple pregnancy is there documented evidence of
discussion regarding the following;
1. The risks and benefits of different modes of delivery Yes No N/A
2. Place of birth Yes No N/A
3. Timing of birth Yes No N/A
4. Individual plan for birth Yes No N/A
32 If there is a pre existing medical / familial reason for antenatal Yes No N/A
Thromboprophylaxis has the appropriate risk assessment been
performed and medical prescribed
33 For women with Type 1 diabetes;
1. Was care given in the joint clinic,
(Obstetrician/Midwife/Diabetic Physician, dietician) Yes No N/A
2. Is there documented evidence the timetable of antenatal
care has been discussed Yes No N/A
3. Has he Diabetes Flow sheet been completed and secured I
the records Yes No N/A
4. Is there documented advise regarding changes in awareness
of Hypo / Hyperglycaemia Yes No N/A
34 For all antenatal admissions was a clear indication for the Yes No N/A
admission documented at the beginning of the episode of care

Labour Care
1 Has the woman completed a birth plan Yes No
2 Is there documented evidence that the birth plan had been Yes No
discussed
3 Have admission observations been completed Yes No
4 Was the woman admitted for an Elective Caesarean Section? Yes No
If yes please go to question 35
5 Is there documented evidence that Fetal monitoring in labour has Yes No
been discussed
6 Is there evidence of discussion regarding he plan of care for labour Yes No
7 Has a review of History taken place and the labour assessed as Yes No
either Low Risk or High Risk
8 Has the fetal heart rate been auscultated and recorded at 15min Yes No
intervals during 1st stage
9 Has it been recorded that the fetal heart was auscultated for 1min Yes No
following a contraction
10 If continuous electronic monitoring is used, has the indication been Yes No N/A
documented
11 Has the Frequency, Length and Strength of contractions been Yes No
recorded every 30 mins

17
12 Has the maternal pulse been recorded hourly, unless it is indicated Yes No
to be more frequent
13 Has the maternal Blood pressure been recorded 4 hourly, unless it Yes No
is indicated to be more frequent
14 Has the maternal temperature been recorded 4 hourly, unless it is Yes No
indicated to be more frequent
15 Has a vaginal examination Yes No
1. Been offered 4 hourly
2. Consent obtained
3. Abdominal palpation performed prior to each VE
16 Has the woman passed urine at least 2-3 hourly Yes No
17 Was action taken if the woman is unable to pass urine Yes No N/A
18 Has the woman’s emotional and psychological needs been Yes No
considered
19 Has the colour of liquor been documented Yes No

20 Has midwifery led care been offered for all low risk women Yes No N/A

21 Has non invasive methods of analgesia including water been Yes No N/A
offered
22 Has the woman been encouraged to adopt alternative positions Yes No
23 Has every effort been made to ensure the woman was actively Yes No
mobile in labour
24 If epidural analgesia was used was;
1. Informed consent obtained Yes No N/A
2. Time of siting reordered Yes No N/A
3. Anaesthetist completed appropriate documentation Yes No N/A
25 If there was delay in the first stage of labour was the following
informed;
1. Deliver Suite Coordinator Yes No N/A
2. Obstetric Registrar Yes No N/A
3. And a plan of care documented Yes No N/A
4. Was the plan appropriate Yes No N/A
26 If Oxytocin was used to augment labour was the following
completed;
1. Assessment by an Obstetrician and appropriate plan of care
documented Yes No N/A
2. Informed consent form the woman Yes No N/A
3. Continuous electronic monitoring of the fetal heart rate Yes No N/A
4. Review by an Obstetrician prior to stopping syntocinon in the
case of fetal compromise Yes No N/A

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27 If there is a pathological recording of the fetal heart rate was;
1. Delivery Suite Coordinator informed Yes No N/A
2. Obstetric Registrar informed Yes No N/A
3. Fetal blood sampling performed / results documented /
secured in the records Yes No N/A
4. Appropriate plan of care documented Yes No N/A
28 Second stage, was;
1. Fetal Heart auscultated / recorded at 5min intervals / Yes No N/A
between contractions
2. Hourly vaginal examination performed, (with consent) Yes No N/A
29 If there was a delay in the Second stage of labour, was the
following informed;
1. Delivery Suite Coordinator Yes No N/A
2. Obstetric Registrar Yes No N/A
3. And a plan of care documented Yes No N/A
4. Was the plan appropriate Yes No N/A
30 Instrumental Delivery
1. Has the indication for instrumental delivery been recorded Yes No N/A
2. The procedure documented appropriately Yes No N/A
31 Has the indication for performing an episiotomy been recorded Yes No N/A
32 Third Stage
1. Has the management been discussed Yes No N/A
2. Was consent obtained prior to administering Syntometrine
for active management of 3rd stage Yes No N/A
3. Has the method of delivery / examination been recorded Yes No N/A
33 Perineal trauma
1. Informed consent obtained for procedure of repair Yes No N/A
2. Has a systematic assessment of perineal and vaginal trauma
been recorded Yes No N/A
3. Effective analgesia given Yes No N/A
4. Anal sphincter integrity reviewed Yes No N/A
5. Record of repair of perineum, including type of suture Yes No N/A
6. Appropriate referral made following 3rd degree tear Yes No N/A
34 Have all drugs administered in labour been recorded on the Yes No N/A
partogram
35 Has the delivery outcome been recorded on the partogram Yes No N/A
36 Has insertion of any Venous Cannula been insertion been recorded Yes No N/A
using cannulation pack sticker
37 If a Urinary catheter was required has the insertion date and time Yes No N/A
been recorded
38 If a fetal scalp electrode was requires, was the date and time Yes No N/A
recorded

19
39 Is there evidence of consent being obtained and removal date and
time for the following;
1. Venous Cannula Yes No N/A
2. Urinary catheter Yes No N/A
3. Epidural Cannula Yes No N/A
4. Fetal scalp electrode Yes No N/A
40 Is there documented evidence of informed consent prior to any Yes No N/A
operative procedure
41 Has the consent form for any operative procedure been secured in Yes No N/A
the records
42 Has the indication for Caesarean section been recorded Yes No N/A
43 Has the category of LSCS been documented Yes No N/A
44 Has the swab count completeness been recorded Yes No N/A
45 Have the anaesthetic record, who checklist, recovery care record Yes No N/A
been completed and secured in the records
46 Have the maternal observation following labour been recorded Yes No N/A
47 Has the woman passed at least 200mls of urine following delivery Yes No N/A
48 Is the labour summary page complete Yes No N/A

Continuous electronic fetal monitoring

(EFM)
1 Is there documented evidence of indication for changing from Yes No N/A
intermittent auscultation to continuous monitoring
2 Is there documented evidence in the recording of the Woman’s Yes No
name
3 Is there documented evidence on the recording of the Date of Yes No
commencement
4 Is there documented evidence on the recording of the Time of Yes No
commencement
5 Is there documented evidence on the recording that chronological Yes No
time is the same as the time printed by the machine
6 Is there documented evidence on the recording of the woman’s Yes No
Hospital number
7 Is there documented evidence on the recording of the Indication Yes No
for commencing the CTG
8 Is there documented evidence on the recording of the woman’s Yes No
pulse at commencement and intermittently throughout the
recording
9 Has the member of staff commencing the recording Signed it and Yes No
printed their name
10 Is there documented evidence on the recording of the fetal heart Yes No
rate heard using Pinard stethoscope at commencement of
recording
20
11 Is there documented evidence on the recording of any events, such
as;
1. Maternal position Yes No N/A
2. Fetal movements Yes No N/A
3. Dilation Yes No N/A
4. Medication given Yes No N/A
5. Vaginal examinations Yes No N/A
6. Description of liquor Yes No N/A
12 When events are annotated, are they recorded at the time of the Yes No N/A
event (i.e. does it correspond to the labour summary)
13 Are all the annotations signed and the time noted Yes No
14 Signature of member of staff reviewing recording Yes No
15 Is there documented evidence on the recording of the date ad time Yes No
of review
16 Is there documented evidence on the recording of the date and Yes No
time of discontinuation
17 Is there documented evidence on the recording of the reason for Yes No
discontinuation
18 Has the member of staff discontinuing the recording signed and Yes No
printed their name

Storage of Continuous electronic fetal

monitoring (EFM) for each recording
19 Is the recording secured in the healthcare records inside CTG Yes No
envelope
20 Is the woman’s details clearly written (label) on the envelope Yes No

21 Is each recording numbered according to the number on the Yes No

envelope
22 Is the date of each recording on the envelope Yes No
23 Is the time and date if each recording on the envelope Yes No
24 Is there documented evidence of hourly assessment of the CTG Yes No
using Dr C Bravado pneumonic

Treatment Cards
25 Is there a treatment card for this episode of care secured in the Yes No
notes
26 Are the women’s details recorded on the card Yes No
27 Is there documented evidence of drug allergies being identified Yes No
28 Is any medication that had been prescribed, written in a legible Yes No
manner
21
29 Is each prescription signed Yes No
30 Is the signature legible Yes No
31 Is there documented evidence that each medication, has been Yes No
administered as prescribed
32 Is there a VTE Risk Assessment attached to the treatment care Yes No
33 Have the VTE Risk Assessment been signed Yes No

Postnatal Care / Documentation regarding

the baby
1 Is there documented evidence of the initial examination by the Yes No
midwife
2 Is there documented evidence of skin to skin contact Yes No
3 Is there documented evidence of first feed including type of feed Yes No
4 Is there documented evidence of the first feed being given whilst Yes No
the woman was in deliver suite, preferably within 1 hour from birth
5 Is there documented evidence of support with positioning and Yes No NA
attachment with the first feed
6 Is there documented evidence of the quality of the feed / amount Yes No
of formula taken
7 Is there a baby care pathway included in records Yes No
8 Has the healthcare professional signed against a coloured pathway Yes No
9 Are the observations completed on the care pathway appropriately Yes No
10 Is there documented evidence of the babies temperature being Yes No
taken following delivery
11 Vitamin K, was there documented evidence of the following;
1. Parental consent Yes No N/A
2. Being administration Yes No N/A
3. Route of administration Yes No N/A
12 Is there documented evidence of baby’s weight and head Yes No
Circumference
13 Are the postnatal notes stored within the main health records Yes No
14 Is there documented evidence of discussion regarding the baby’s Yes No N/A
security whilst in hospital
15 Is there documented evidence of an individualised plan of care Yes No
plan, the woman and her baby
16 Is the infant feeding Postnatal check list completed and secured in Yes No
the records
17 Is there documented evidence of appropriate instruction in Yes No N/A
sterilisation of feeding equipment / reconstitution of feeds
18 Is there documented evidence of the woman being offered an Yes No
opportunity to discuss the birth
22
19 Is there documented evidence of plan of care following transfer Yes No
home from hospital
20 Is there documented evidence of the baby having had a full Yes No
physical neonatal examination
21 For women with multiagency / multidisciplinary needs is there Yes No
evidence of coordination between all concerned
22 Is it documented that the NICE Postnatal guidance including Yes No
information for parents to be able to assess their baby’s well being
has been given
23 Have contact details been given for support from the relevant Yes No
healthcare professionals
24 Is there documented evidence of the baby’s red book being given Yes No
to the parents to discuss

Support for parents in case of actual or

suspected poor outcome for the newborn
If no fetal / neonatal loss go to question 30
25 is there documented evidence of support from appropriate Yes No N/A
healthcare professionals
26 Is there documented evidence of the provision of written Yes No N/A
information
27 Is there documented evidence of the parents being given Yes No N/A
information regarding support groups
28 Is there documented evidence of discussions had between Yes No N/A
healthcare professional and parents, regarding care and advice
29 Is there documented evidence of support for parents who have Yes No N/A
communication or language support needs?

General Record Keeping

30 Is all documentation written legibly in manner that the text cannot Yes No
be erased
31 Is all documentation written in black ink Yes No
32 Are all entries recorded contemporaneously Yes No
33 Is all the women’s name and unit number recorded on each loose Yes No
page / inserts
34 Are all entries dated and times using the 24 hour clock Yes No
35 Are all entries signed Yes No
36 Is the name printed and qualification stated by each health Yes No
professional making an entry
37 Is all information in chronological order Yes No
38 Have all handovers of care been clearly identifies Yes No
39 If abbreviations have been used have they previously explained (or Yes No
agreed by the trust)
23
40 Are all errors crossed once, dated, timed and signed the words Yes No
‘written in error’ entered
41 Are all records factual, free from; jargon, meaningless phrases, Yes No
irrelevant speculation and subjective statements
42 Are all documents / loose papers filed in chronological order Yes No
securely
43 If the woman has had an operative procedure is the anaesthetic Yes No
record secured in the records
44 If a fetal blood sample or paired samples were taken are the results Yes No
secured in the records
45 Are the Ultra scan reports secured in the records Yes No
46 Is there any evidence of records from previous pregnancies being Yes No
filed with this pregnancy
47 Are any scraps of paper, e.g. used for noting times of events, Yes No
secured in the records, in a visible manner

Postnatal Care / Documentation regarding

the mother
1 Is there documented evidence of delivery summary yes no
2 Is there documented evidence of thromboprophylaxis risk yes no
assessment
3 Is Home birth check list done if Applicable Yes no
4 Is postnatal handover complete yes no
5 Is transfer from hospital to community filled in yes no
6 Is infant feeding checklist complete yes no
7 Is each entry timed dated and signed yes no
8 Is modified early obstetric warning system filled in yes no
9 Has community discharge letter been completed yes no
10 Are the notes stored within the main notes yes no

24