[CG] Record keeping guidelines

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The following standards should be observed when keeping records

  • Be factual, consistent and accurate
  • Be written as soon as possible after an event has occurred, providing current information on the care and condition of the patient or client
  • Be written clearly and in such a manner that the text cannot be erased
  • Be written in such a manner that any alterations or additions are dated, timed and signed in such a way that the original entry can still be read clearly: i.e. using one line to score out
  • Be accurately dated, timed and signed, with the signature printed alongside the first entry. First entry in the obstetric case record should include an entry including usual signature as a specimen in the relevant section at the back of the record. Entries made by students should be countersigned by the member of staff supervising their work.
  • Subsequent entries must provide legible signatures and status
  • Observe locally agreed abbreviations only
  • Ensure that all documentation contains a patient identifier
  • Only write in black biro Writing must be legible and indelible

The records will demonstrate a chronology of events with all significant consultations, assessments, observations, decisions, interventions, and outcomes

Retrospective entries must be annotated as such and dated and timed at the time the entry is made into the record.

  • There will be evidence of informed consent by the woman for procedures
  • There will be no jargon, meaningless phrases, irrelevant speculation and offensive subjective statements

In addition Records should:

  • Be written in terms that the patient can understand
  • Be consecutive
  • Identify problems that have arisen and the action taken to rectify them

Provide clear evidence of the care planned, the decisions made, the care delivered and the information shared

References

GMC Guidance on Good Practice 

NMC Record Keeping: Guidance for Nurses and Midwives July 2009. Due review in 2012.

Last reviewed: 14 December 2009

Next review: 01 August 2021

Author(s): Evelyn Frame

Approved By: Obstetric Guideline Group