Documentation

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Good documentation is an essential part of providing high-quality care and helps ensure clear communication and appropriate care planning. The chart is a tool that facilitates communication between care providers during the course providing care. It is also the record that informs discussions and reviews about the care that was provided, and can provide data for research or quality improvement initiatives. According to HIROC’s guide on documentation and documentation webinar (coming soon to our online store!), quality charting is:

  • accurate,

  • chronological,

  • permanent,

  • legible, and

  • contemporaneous.

The record should provide a complete and cohesive story of the clinical situation, the plan of care and the care provided to the client, including who provided the care, when, why and the outcomes for the client.

Changes in patient status such as deteriorating status, changes in choices made by the client or new information to be considered in the plan of care should be clearly documented. Documentation should include what was communicated to the client, any changes in the recommended plan of care and the care chosen by the client.

Here are some tips and tools for charting:

  • Be aware of and comply with the College of Midwives of Ontario’s (CMO) Record Keeping Standard for Midwives, which include the information to be contained in every chart, record retention, confidentiality, sharing of records, and the use of protocols and checklists.
  • Standardized forms facilitate consistent charting and support clear and comprehensive communication between care providers. During the antenatal period, Ontario midwives and physicians use the Ontario Perinatal Record produced by the Ministry of Health and Long-Term Care. The AOM has developed a standard set of forms for charting intrapartum and postpartum care.
  • Transitions of care, such as consultations, transfers of care and discharge warrant particular attention to charting as they are an opportunity for miscommunication and misunderstandings. The management plan needs to always be clear to anyone opening the chart and taking over care.
  • Informed choice discussions are documented in detail that reflects the level of risk that the client is accepting. More detailed charting is warranted when a client’s choice differs from a midwife's recommendations, practice protocols, hospital protocols or other community standards; or if the midwife’s recommendation differs from guidelines or protocols. For further information, refer to the page on informed choice and protocols and the CMO standard on When a Client Chooses Care Outside Midwifery Standards of Practice.
  • Urgent and emergency situations present special additional challenges, particularly to contemporaneous charting. Practical advice on documenting informed discussions and charting in urgent and emergency situations is provided in the AOM Emergency Skills Workbook and the AOM webinar on documentation.
  • Email and text messages are generally inferior means of communicating with clients because of the loss of body language and tone, and the tendency towards brevity. Where circumstances necessitate the use of email or text to communicate with clients about care, they should be recorded in the chart either in a narrative note or by printing/ saving the communication in the chart.
  • Safe file storage protects records from fires and floods; backing-up electronic records avoids inadvertent loss. Client records must also be protected from privacy breaches.
  • Record retention policies reflect limitation periods and legislative requirements to maintain records to make sure that the practice has the records it needs when it needs them. Look under the Financial tab on our Protocols page to find a sample policy.