Midwifery care records serve a multitude of purposes, for different audiences.
To meet their professional and legal obligations midwives are required to keep effective and thorough records of the care they provide, including documenting all decisions made with their clients. To determine the best approach to record keeping, it is necessary first to understand the multiple purposes which that documentation serves.
Bridget Kerkin, Dr Jean Patterson, both from Otago Polytechnic, and Dr Susan Lennox, a midwifery consultant, investigated the purposes for documenting midwifery care. Their enquiry drew on other healthcare fields as well. They found that documentation of care can serve any or all of the following purposes:
- Enhancing the woman-midwife partnership through clear communication
- Contributing to continuity of care and transition between health professionals
- Providing clarity of communication in a multidisciplinary care environment
- Improving standards of care, recognising the woman's priorities for herself and her baby
- Enabling effective auditing and clinical review
- Collecting data to inform future service improvements
- Contributing to the professional research environment and best practice
- Improving the visibility of the work of midwives
- Facilitating self-reflection and learning by midwives
- Meeting professional expectations and accountability
- Constituting a legal record in the event of any review of care
- Recording each woman's experience
Whilst many of the purposes of midwifery documentation are shared with other professions there are also differences. This research makes those differences explicit and in doing so taps a rich and under-explored vein in midwifery’s body of knowledge.