Documentation and record keeping

Midwives have an obligation to provide a meaningful, useful, and thorough record of care, which includes all midwifery care provided, advice given, discussions, and the outcomes arising from discussions which are updated on the care plan. This audit tool is designed to ensure midwives are meeting minimum competence standards for registration related to documentation. It is designed to be used alongside other resources for midwifery documentation and record-keeping, such as:

In order for midwives to periodically review their documentation practice we encourage self and/or peer review. This has been shown as an effective method for improving clinical practise. Review provides a systematic method to ensure that practice meets professional competencies and legislative requirements, and should include review of over health record management systems.

 

Regular audit using the tool (at least yearly) will enable:

  • A methodical method to identify risks related to documentation practice
  • A means to seek feedback and improve professional practice
  • Identification of any gaps in your documentation practice
  • A proactive method to improve quality

The Midwifery Documentation and Record Keeping Audit Tool.