Introduction
This chapter discusses and analyses the legal and professional framework that governs midwifery practice and the accountability of the midwife in relation to the documentation of her records. Activities and practical exercises are included throughout to help you to integrate the theory of the topic area with practice and offer some practical advice and guidance for how you can improve your personal standard of record keeping.
The standards and guidance produced by our regulatory body, the Nursing and Midwifery Council (NMC), concerning the role and responsibilities of the midwife in the context of effective documentation and professional practice (NMC 2008, 2009a, 2012a) will be explored, analysed and applied to practice. It is anticipated that having read this chapter, the reader will be able to describe the various forms of record keeping used in contemporary practice and discuss the rationale for maintaining comprehensive, contemporaneous records in relation to professional accountability. A self and peer audit tool for monitoring the standard of records will be introduced to enable the reader to apply the knowledge and skills in practice, to evaluate and enhance the development of their own record keeping competencies.
The importance of effective documentation
The Nursing and Midwifery Council came into being on 1 April 2002. It succeeded the former professional body, the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC). With the establishment of the NMC, the new rules for midwives came into effect on 1 January 2013 and the NMC will continue to state the requirements for practice and provide guidance on what standard would reasonably be expected from a midwife’s practice.
Rule 6 relates specifically to records (NMC 2012a, p16). The NMC states that:
Good record keeping is an integral part of nursing and midwifery practice, and is essential to the provision of safe and effective care. It is not an optional extra to be fitted in if circumstances allow.
(NMC 2009a, p3)
The Midwives’ Rules and Standards make it clear that midwives are accountable for the quality and retention of their documentation (NMC 2012a). ‘All records relating to the care of the woman or baby must be kept securely for 25 years’ (p18). This ruling applies wherever the midwife carries out her duty, whether in a private, agency, independent or National Health Service (NHS) context.
Effective documentation is part of the midwife’s duty of care. Within this, the midwife is expected to use professional judgement to make decisions that will enhance client care through her documentation. The NMC states in the Guidelines for Records and Record Keeping that it ‘is not a rule book that will provide the answers to every question or issue that could ever arise’ (NMC 2005, p5). However, the intention is that it should be used for guidance together with the Midwives’ Rules and Standards to strive for excellence in record keeping.
The importance of accurate and contemporaneous record keeping cannot be overstated. Indeed, according to Gallagher and Hodge (2012, p18), ‘a way of protecting yourself from allegations of incompetence, unprofessional practice or other breach of codes, is records, records and yet more records’.
Good record keeping equates with good care
‘Good record keeping helps to protect the welfare of patients and clients’ (NMC 2005, p6). Its value has been consistently identified and highlighted in various professional guidelines (NMC 2005, 2006, 2011c, DH 2006).
In summary, good record keeping promotes:
- high standards of clinical care
- continuity of care
- better communication and dissemination of information between members of the interprofessional healthcare team
- an accurate account of treatment, care planning and delivery
- the ability to detect problems, such as changes in the patient’s or client’s condition, at an early stage
- the professional duty to keep adequate and accurate records
- the ability of the midwife practitioner to meet legal requirements.
The NMC asserts that the quality of your record keeping is also a reflection of the standard of your professional practice (NMC 2009a).
Review a client’s record that you have written in during the previous 6 months and assess the quality of the content and style of your documentation. Now go to the feedback box below for guidance and suggestions.- It is factual, consistent and accurate.
- It is written as soon as possible after the event or an explanation given when written retrospectively, for example why the delay in writing the records became necessary.
- It is clear, concise and legible, written in ink (must be able to be photocopied if necessary) (Dimond 2005).
- It is signed and your name printed (according to the format for the trust or other employer).
- It should be dated and the time included using a 24-hour clock.
- Jargon, abbreviations, irrelevant speculation and offensive subjective statements should not be included.
- Any dialogue with the patient/client should be included in a form that would provide evidence of client participation in their care.
- Any alterations or additions are dated, timed and signed in such a way that the original entry can still be clearly read.
- There is evidence that the client collaborated with the practitioner in the construction of the records; for example, statements from the client are included in language that supports the client’s involvement.
- The tone and quality of the communication are such that the client’s understanding is ensured.
How did your record keeping compare with the contents of the feedback section? Reflect on this exercise and identify areas for further development.
Record keeping: the extent of the current challenges
The NMC is the statutory body which regulates the practice of nurses, midwives and specialist community public health nurses. The roles and functions of the NMC and how these impact on practitioners are explored in greater detail in Chapter 13 [ED: please check chapter cross-reference]. One of the largest departments at the NMC is the Fitness to Practise Directorate. This manages all complaints of allegations relating to the standards and conduct of practitioners’ practice. Each year a Fitness to Practise Report is published which reviews the nature of the complaints that have been reported to the NMC throughout the previous year, how they have been managed and the outcome of the hearings. In the most recent report, 2010–2011 (NMC 2011a), the NMC states that there are almost 670,000 nurses and midwives registered to practise in the UK and there were 4,211 new cases referred to the NMC for investigation during 2010–2011. To put this in context, this accounts for only 0.3% of all practitioners, and midwives make up only a small proportion of this percentage because there are significantly fewer midwives on the register compared to the numbers of nurses. However, the Fitness to Practise Directorate generates the highest expenditure of all the NMC departments as it is a costly exercise to investigate a registrant’s conduct and therefore utilises most of the finances from practitioners’ annual fees.
When we look further to ascertain the categories of complaints received by the NMC (2011a), record keeping, including failure to maintain adequate records, accounts for approximately 4% of all complaints, coming in at a shared fourth place in a total of 12 categories (dishonesty, including theft or obtaining goods by deception, being the most common complaint). One could argue that dishonesty is to do with conduct, whereas the skill of record keeping is a competency-based activity and if we adopt that view, then record keeping could be included within the second most common category, competency issues. Poor record keeping is a significant practice issue, which could ultimately mean that a midwife could be removed from the register if she fails to reach the required standard.
Included in its other statutory functions, the NMC also has a responsibility under the Nursing and Midwifery Order 2001 (SI 2002 No. 253) to monitor the performance of the local supervising authorities (LSA) to ensure they are meeting the required standards for statutory Supervision of Midwives. Supervision of Midwives is a framework for supporting midwives and safeguarding mothers and their babies and provides a mechanism for every practising midwife in the UK (LSAMO National Forum 2009). It is a unique instrument, in that midwifery is the only profession to enjoy the benefits of Supervision of Midwives (SoM). Chapter 19 [ED: please check chapter cross-reference] explains the function of Supervision of Midwives further. Under the current Midwives’ Rules (rule 13) (NMC 2012a), each of the 15 LSA regions must submit an annual report to the NMC, which analyses the contents to ensure the standards for SoM are being met. One of these standards determines the ‘Details of how the practice of midwives is supervised’ (NMC 2012b, p28). As record keeping is a key aspect of midwifery practice, this will impact on many areas identified in the annual report Supervision, Support and Safety: NMC quality assurance of the LSAs 2010–2011 (NMC 2012b).
Midwives are working in increasingly demanding clinical environments. Examples include increasing birth rates, increasing numbers of women with diverse cultures and complex physical needs, such as obesity, women with high-risk pregnancies wishing to birth at home and in some areas, midwives working with limited resources and staff shortages. Whilst ‘being busy’ is by no means a mitigation for poor or absent record keeping, given the pressures some midwives face on a regular basis, one could see how for some, record keeping might not always be the top priority. However, this view would not be shared by the NMC at a Fitness to Practise Conduct and Competence Committee. Of the themes arising from all LSA investigations undertaken in the preceding year, record keeping features as the third most common factor resulting in supervised practice. Substandard record keeping is also mirrored in the Annual Fitness to Practise Report (NMC 2011a) and in the Confidential Enquiry into Maternal Deaths report (Centre for Maternal Child Enquiry 2011). There is no question that poor or absent record keeping is still one of the most common issues in nursing and midwifery, affecting care for babies and mothers. Despite the increasing levels in education for pre-registration programmes and the move towards an all-graduate profession for nurses and direct-entry midwifery (NMC 2009b, 2010), the standards of record keeping remain variable from year to year.
The NMC’s Fitness to Practise processes focus on individual practitioners. This is appropriate as every nurse and midwife is accountable for her own practice. This means she/he is professionally accountable to the NMC and furthermore, she/he has a contractual accountability to her employer, in addition to UK law, for her actions. Students are accountable to the approved education institute at which they are registered to undertake their nursing or midwifery training and must also abide by the policies and protocols of the trust where they undertake their clinical practice placements (NMC 2011b). The code explains ‘accountability’ in terms of taking individual responsibility, stating that, ‘As a professional, you are personally accountable for actions and omissions in your practice and must always be able to justify your decisions’ (NMC 2008, p1). With regard to record keeping, to put it simply, you are responsible for the content and quality of your records and cannot blame someone else or the circumstances if your record keeping is not up to standard.
NMC Annual Fitness to Practise Reports and Statistics- How many new cases were referred to the NMC in the most recent report and what percentage of these were women?
- How many men and women received a striking-off order?
- Who is the most common source of referral of cases to the NMC?
- In relation to standards of record keeping, compare and contrast the percentage of cases of poor record keeping in the reports.
- Consider the factors that could impact on the percentage rates.
A review of a recent case that came to the Fitness to Practise Conduct and Competence Committee hearing illustrates how a midwife’s record keeping which did not meet the required standard was her responsibility. However, the organisation where she was employed operated a practice culture which did little to proactively support good standards of record keeping. A series of events combined on a particular day and resulted in a series of life-threatening events for the mother and her baby. Below is a summary of the case. Read it, and then use the activities to reflect by yourself or with your colleagues on the accountability of Midwife B and the other factors which contributed to the events.
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