Keeping accurate records

The Nursing and Midwifery Council's revised Code (NMC, 2015) imposes a duty on midwives to keep clear and accurate records relevant to their practice. To discharge the duty set out in standard 10 of the Code, midwives must show that they:

The primary purpose of keeping records is to have an account of the care and treatment given to a woman and baby. As well as their clinical function, records have an important legal purpose. Records provide evidence of a midwife's involvement with a woman and baby. They need to be sufficiently detailed to demonstrate that the midwife has discharged his or her duty of care.

To be of value as evidence, record entries must be accurate, clear and reliable. The reliability of a record entry is enhanced by it being made contemporaneously, at the time of or immediately following contact with a woman. Contemporaneous entries minimise errors caused by having to recall from memory the care and treatment that was provided to a patient.