Transitions in Care
Documentation during transitions in care, such as consultations, transfers of care, or when a client is discharged, warrant special considerations. HIROC’s experience with midwifery claims confirms that miscommunications during these transitions place clients at risk. Consultations, transfers of care and shared or supportive care should be done in compliance with the following relevant College of Midwives of Ontario standards:
Requests for consultation should include a clear description of the reason for the request and the urgency of the referral. When documenting intrapartum or urgent consultation requests, include the exact time the request was made, who communicated with the consultant, the method of communication (e.g. phone, pager, locating service, etc.), what information was conveyed (e.g., urgency) and the response (e.g., whether the consultant agreed to attend and the expected time of attendance). Any subsequent calls updating the consultant or repeating the request for timely attendance should be similarly documented.
Although the consultant is responsible for documenting the consultation, it is also important for the midwife to document her or his understanding of when the consultation actually took place, the assessment, recommendations and the client’s choices about the plan of care.
When a client declines a consultation recommended by the midwife or chooses care different than the consultant’s recommendation, the informed choice discussion should be documented, including a brief summary of the risks and benefits of the client’s choice and the steps taken by the midwife to ensure that these were clearly understood by the client.
Documentation about a consultation should also clearly describe the roles and responsibilities of the consultant and the midwife in the ongoing plan of care. Document who is the most responsible care provider and the division of responsibilities. This should include who will perform procedures, run tests and check lab and diagnostic imaging results and communicate them to the client and the care team. For further information, see the CMO standard Interprofessional Collaboration.
Transfers of Care
When transferring care to another health-care provider, the midwife remains the primary care provider until the receiving health professional acknowledges (in writing if possible) that they have accepted the transfer. Midwives need to share the information necessary to ensure the safe transfer of care.
When care is transferred, ensure that changes in the care plan are effectively communicated to all involved (e.g., the client, other midwives) and are clearly documented in the client record. After care is transferred, the midwife need not document the care provided by others, but should continue to document midwifery care provided in shared care or supportive care roles. The midwife should also communicate and document clearly when accepting care back, if applicable.
Transferring Into Hospital from a Home Birth
Hospitals generally require that copies of antenatal record forms be placed in the hospital chart prenatally. Requirements for additional information such as ultrasound reports may vary between hospitals. Regardless of hospital policy, midwives should provide the essential information required for ongoing care, and ensure it is copied into the hospital chart.
When a midwife attends a labour or birth at home and there is a subsequent transfer to hospital, the midwife should write an admission or transfer summary which includes all pertinent information and history. This is recommended whether the client will be admitted under the care of the midwife or if there will be a transfer of care. If the admission or transfer summary is sufficiently detailed, HIROC and legal counsel have advised that the home labour record not be copied into the hospital chart. The more complex the history, the more detail must be shared, which could include copies of test results and diagnostic imaging reports. The objective is to facilitate the best communication possible in order to obtain the best ongoing care for the client.
Anything which occurs after arrival in the hospital should be documented in the hospital chart rather than the home birth record or clinic chart (other than any necessary back charting of events that occurred prior to arrival). HIROC and legal counsel advise that hospitals have an obligation to midwives to provide copies of hospital records to midwives, just as they do to physicians, on request when they are needed as they might be for legal purposes.
As part of safe practice, HIROC recommends that, along with verbal instructions, midwives provide clear written instructions to clients prior to a transfer or discharge. Depending on the circumstances of the transfer, instructions may include:
- signs and symptoms to watch for (e.g. jaundice and postpartum depression),
- when and how to seek help (e.g. emergency department, family physician, nurse practitioner, etc.),
- resources in the community (e.g. public health nurse, support groups), and
- the dates and times of any follow-up appointments.
- If care is being transferred to an as yet unknown care provider, the instructions should also include information on what treatment or tests have or haven’t been performed and when (e.g. GBS screening, Rh factor testing, newborn screen, last Pap test).
These instructions can then be noted in the chart just as you would note any other discussion or information provided to clients. A copy of individualized written instructions should be added to the chart. If your practice group uses standard discharge instructions, similar to standard paging instructions, you could note that you provided and reviewed the instruction sheet rather than noting each individual element that was discussed. Remember to keep all versions of any standard instructions (see the record retention protocol under "Financial"), documenting the time frame in which each version was in use.
Sample protocol(s), submitted by midwifery practices, are available on emergency transfer/transport for out-of-hospital births for practices to download and adapt. Be sure to tailor the template to reflect current evidence, best practices and practice group/community specific information before use