RECORD KEEPING

1
RECORD KEEPING

• A Barrister's view
• Laura McMahon BL

2
When might we meet?

• Civil claims
• Criminal cases
• Inquests
• Inquiries
• NMC hearing

3
What documents will I ask for?

• All midwives notes, however recorded
• All medical notes
• GP notes
• All administrative correspondence
• Notes from other patients being cared for at the
  same time/within same timeframe
• All computer held notes
• Woman-held notes
• Personnel files as relevant, e.g. previous
  disciplinary
• Midwife expert reports
• Letters of complaint relating to similar
  treatment and/or the same midwife
• Notes of all meetings with woman/family with any
  and all healthcare professional
• Supervision notes

4
Midwifery training

• Compassionate
• Caring
• Patient centred
• Empathic
• Professional
• Accountable
• Hierarchical

5
Barrister training

• Detached
• Individualistic
• Objective
• Analytical
• Adversarial
• Inquisitorial
• Forensic

6
What I look for in notes

• Chronological order for all actions
• Referrals not clearly indicated, reviewed and
  documented
• Inconsistency within midwifery notes and other
  professional notes
• Failure to cite facts to support
  statements/findings and care plans
• Failure to give conclusions or base conclusions
  on the evidence
• Failure to document the name of doctor informed
  of patient condition
• Opinion without facts
• Supposition/assumptions without facts or action
• Failure to follow a logical order
• "Wait and see"
• Absence of evidence that info has been
  given/risks explained
• Absence of woman's signature around
  info/risks/consent

7
Remember

• Protect your patient AND your practice
• Assume everything you write or document in any
  format will be accessed by someone at some stage
• If in doubt, always seek advice within line
  management or among other healthcare
  professionals involved in patient care.
• If its not recorded its not done
• If it's not signed/witnessed it's not done
• Ensure issues around risk and consent are recorded