References

Hall v North Hertfordshire NHS Trust. 2016;

London: NMC; 2015

Keeping accurate records

02 August 2016
Volume 24 · Issue 8

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:

  • Complete all records at the time or as soon as possible after an event, recording whether the notes are written some time after the event
  • Identify any risks or problems that have arisen and the steps taken to deal with them, so that colleagues who use the records have all the information they need
  • Complete all records accurately and without any falsification, taking immediate and appropriate action if you become aware that someone has not kept to these requirements
  • Attribute any entries you make in any paper or electronic records to yourself, making sure they are clearly written, dated and timed, and do not include unnecessary abbreviations, jargon or speculation
  • Take all steps to make sure that all records are kept securely
  • Collect, treat and store all data and research findings appropriately.
  • The purpose of record-keeping

    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.

    Contemporaneous entries

    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.

    A contemporaneous entry also enhances the credibility and reliability of the record as evidence. As a midwife's contact with women is mainly on a one-to-one basis, records made at the time of, or soon after, attending a woman often provide the necessary evidence to support a midwife's recollection of an event.

    Records must be accurate

    To confirm the chronology of record entries, each entry must be identified with the date (day, month and year) and time (using the 24-hour clock), and signed, with the midwife's name printed legibly underneath the signature, together with his or her position. Initials for entries must not be used, as it is vital to be able to identify the member of staff if a complaint is made.

    Errors

    All alterations must be made by scoring out with a single line that does not completely obscure the error. Correcting fluid must not be used; this removes any suggestion of wrongdoing or attempting to cover up an incident. The struck-out error should be followed by the dated, timed and signed correct entry. No blank lines or spaces that could facilitate entries being added at a later date should be left between entries.

    The record should demonstrate the chronology of events and of all significant consultations, assessments, observations, decisions, interventions and outcomes. Reports and results should be seen, evaluated and signed by the midwife before being filed in the records. This is the key to a good record.

    Legal implications of records

    Any document that records any aspect of the care of a woman can be required as evidence before a court of law or before any of the regulatory bodies. There is no restriction on access to these documents. The rules of the court demand that all documents are produced (Rules of the Supreme Court Order 24). It is important, therefore, that midwives do not view record-keeping as a mechanistic process. What you write does matter. In litigation, the outcome is not based on truth, but proof. If something is not in the notes, it can be difficult to prove it happened. Cases are won and lost on the strength of records. Records are never neutral, they will either support you or condemn you.

    Two cases highlight the importance of accurate, reliable, contemporaneous records as evidence, and how they influence the outcome in court.

    In Hall v North Hertfordshire NHS Trust 2016, a woman claimed for personal injury, loss and damage arising out of the birth of her baby. She had been under the care of a midwife and a first-year student midwife on the night that she gave birth. She had been standing by her bed with the student midwife kneeling behind her, while the midwife had been at the other side of the bed switching on a machine in preparation for the birth. The baby fell directly onto a pillow between the claimant's legs. The umbilical cord snapped during the fall and the baby appeared to have mild bruising the following day, but was otherwise unharmed. The woman argued that the midwife had failed to control the baby's descent and had left an inexperienced student to deal with the delivery, and as a result the woman had suffered post-traumatic stress disorder and depression.

    The court held that the midwife was an honest witness and her notes were accurate, reliable and contemporaneous. They gave a clear, frank, consistent and balanced account of the management of the labour and the court accepted that it had been reasonable for the midwife to leave the claimant for the short time it took to switch the machine on, as delivery at that time could not have been reasonably foreseen. It was an exceptional case. The whole picture indicated that labour had been progressing to delivery, but that it had been unlikely to happen within a few minutes. The student kneeling behind the claimant had not been directed to deliver the baby, but to observe the claimant. The midwife had acted reasonably and in accordance with a reasonable body of midwifery opinion.

    It is clear from the judge's comments that the midwife's records supported her case and influenced his findings. Where records are less clear, the outcome is generally very different. In S (A Child) v Newcastle & North Tyneside HA [2001] it was alleged that the negligent management of the latter stages of labour resulted in severe cerebral palsy. The judge's annoyance at the poor quality of record-keeping is clear to read:

    ‘It is important to emphasise at this early stage that unhappily the evidence was, in certain important respects, incomplete. The clinical records of this labour are not full and no records at all appear between 4 a.m. and 10.15 a.m. Each of these might be regarded as critical periods. Unhappily who ever did take over from [the midwife] singularly failed to complete the partogram which is effectively devoid of useful information…’

    S (A Child) v Newcastle & North Tyneside HA [2001] (Deputy Judge Brown at [5])

    The midwife was held to be negligent, with her records condemned as limited and contradictory, and damages were awarded to the baby.

    Conclusion

    The NMC, with good reason, considers clear, accurate record-keeping as a fundamental aspect of a midwife's duty towards the women and babies in his or her care. Records are crucial in monitoring progress and communicating concerns.

    Records also have a vital role in protecting midwives from litigation and allegations of unprofessional behaviour. Thorough, contemporaneous, legible records will protect midwives by providing robust evidence of their involvement with a woman and her baby. In this way, they will demonstrate that the midwife has met the requirements of the Code (NMC, 2015) and his or her legal and professional obligations, by setting out how he or she has discharged the duty of care.