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CANTERBURY CHRIST CHURCH UNIVERSITY FACULTY OF HEALTH AND SOCIAL CARE
BSc (Hons) Midwifery
Interprofessional Learning Programme
MIDWIFERY TRANSCRIPT – Including Sign off Mentor end of year summary
NAME: ___________________________________________ COHORT: ____________________ CLINICAL BASE: _____________________________________ PROGRAMME COMMENCED: _________________ PROGRAMME COMPLETED: ___________________ A comprehensive and accurate record of your clinical experience is a statutory requirement of your Midwifery Education Programme. It is the responsibility of the student to fill in the record daily, and to make it available to your personal tutor, mentor and sign off mentor
INSTRUCTIONS TO THE STUDENT: - You are responsible for seeing that: Confidentiality is maintained. Consent is gained from women to document their care in the Transcript and share this information with your tutors. You store this document appropriately since the information is confidential. You photocopy pages if more space is required and secure these into the Transcript. You provide your sign off mentor with this document at the end of each year.
1
European Union Midwifery Directive (80/155/EEC Article 4) lists the following clinical experience which you are required to achieve and record at least:
• Parent Education • Booking histories taken • 100 pre-natal examinations • Witness up to 5 ‘low risk’ labours • Conduct 40 ‘low risk’ labours • Episiotomies and suturing experience • Women cared for with epidurals in situ • Women assisted with inhalation analgesia and TENS • 40 newborn baby checks. • 100 postnatal checks (women) • 100 postnatal checks (babies) • Involvement in the care of 40 ‘high risk’ women in the antenatal, intranatal or postnatal period.
Please continue to record your experiences once the minimum requirement achieved.
2
PRACTICE LEARNING FACILITATORS (MENTORS) Print name PLF’s signature Area of practice Print name PLF’s signature Area of practice
3
FINAL GRADE FOR PRACTICE – End of Year One
LINK LECTURER AND SIGN OFF MENTOR
Community/Hospital Year 1 MARK AWARDED Community/Hospital Year 1 MARK AWARDED
TOTAL = %
2 Hospital Trust.................................................................................... Sign off mentor signature................................................................. Link Lecturer signature...................................................................... Student signature.............................................................................. Date...........................................
4
YEAR ONE-
Student reflection of Year 1 practice experience.
Signature:
Date:
5
SIGN OFF MENTOR END OF YEAR SUMMARY – (suggestions- comment on progression through the year, considering strengths & challenges, overall clinical grade and suggestions for the coming year)
Signature:
Date:
6
Year 1 Feedback from service users. This section is intended for feedback from the service user / or their family. The mentor should identify a suitable client who the student has been working with and ask if they would mind giving the student feedback on their performance. This can be written by the service user or if they would prefer it, a summary of their feedback can be written by the mentor.
Signature:
Date:
7
FINAL GRADE FOR PRACTICE- End of Year Two
LINK LECTURER AND SIGN OFF MENTOR
Community/Hospital Year 2 MARK AWARDED Community/Hospital Year 2 MARK AWARDED
TOTAL = %
2 Hospital Trust.................................................................................... Sign off mentor signature................................................................. Link Lecturer signature...................................................................... Student signature.............................................................................. Date...........................................
8
YEAR TWO-
Student reflection of year 2 practice experience.
Signature:
Date:
9
SIGN OFF MENTOR END OF YEAR SUMMARY-(suggestions- comment on progression through the year, considering strengths & challenges, overall clinical grade and suggestions for the coming year)
Signature:
Date:
10
Year 2 Feedback from service users. This section is intended for feedback from the service user /or their family. The mentor should identify a suitable client who the student has been working with and ask if they would mind giving the student feedback on their performance. This can be written by the service user or if they would prefer it, a summary of their feedback can be written by the mentor.
Signature:
Date:
11
FINAL GRADE FOR PRACTICE - End of Year Three
LINK LECTURER AND SIGN OFF MENTOR
Community/Hospital Year 3 MARK AWARDED Community/Hospital Year 3 MARK AWARDED
TOTAL = %
2 Hospital Trust.................................................................................... Sign off mentor signature................................................................. Link Lecturer signature...................................................................... Student signature.............................................................................. Date...........................................
12
YEAR THREE-
Student reflection of year 3 practice experience.
Signature:
Date:
13
SIGN OFF MENTOR END OF YEAR SUMMARY-(suggestions- comment on progression through the year, considering strengths & challenges, overall clinical grade and suggestions for future learning once qualified)
Signature:
Date:
14
Year 3 Feedback from service users. This section is intended for feedback from the service user / or their family. The mentor should identify a suitable client who the student has been working with and ask if they would mind giving the student feedback on their performance. This can be written by the service user or if they would prefer it, a summary of their feedback can be written by the mentor. Signature:
Date:
15
ANTENATAL BOOKINGS
DATE & TIME Of EVENT
CLI
ENT
INIT
IALS
Consent to use data √
GESTATION
PARITY
ALTERED HEALTH CONDITIONS OR OTHER FACTORS
16
OTHER CLINICAL EXPERIENCE PAEDIATRIC FOLLOW-UP CHILD HEALTH CLINICS FAMILY PLANNING OUTPATIENT CLINICS DATE
NUMBER OF CASES SEEN
DATE NUMBER OF CASES SEEN
DATE NUMBER OF CASES SEEN
DATE Type of clinics
17
PARENT/HEALTH EDUCATION
Record group and individual teaching/education incidences for example: parent craft, aerobics, aquarobics, children centres, preparation and support for breastfeeding/artificial feeding.
DATE SESSION CONTENT
18
ANTENATAL EXAMINATIONS – MINIMUM 100 EXAMINATIONS.
DATE/TIME EVENT
NO.
GESTATION
CLIENT INITIALS
Consent to use data √
DATE/TIME EVENT
NO.
GESTATION
CLIENT INITIALS
Consent to use data √
01 26 02 27 03 28 04 29 05 30 06 31 07 32 08 33 09 34 10 35 11 36 12 37 13 38 14 30 15 40 16 41 17 42 18 43 19 44 20 45 21 46 22 47 23 48 24 49 25 50
19
DATE/TIME EVENT
NO.
GESTATION
CLIENT INITIALS
Consent to use data √
DATE/TIME EVENT
NO.
GESTATION
CLIENT INITIALS
Consent to use data √
51 76 52 77 53 78 54 79 55 80 56 81 57 82 58 83 59 84 60 85 61 86 62 87 63 88 64 89 65 90 66 91 67 92 68 93 69 94 70 95 71 96 72 97 73 98 74 99 75 100
20
Continuation sheet
DATE/TIME EVENT
NO.
GESTATION
CLIENT INITIALS
Consent to use data √
DATE/TIME EVENT
NO.
GESTATION
CLIENT INITIALS
Consent to use data √
21
Continuation sheet
DATE/TIME EVENT
NO.
GESTATION
CLIENT INITIALS
Consent to use data √
DATE/TIME EVENT
NO.
GESTATION
CLIENT INITIALS
Consent to use data √
22
SUPERVISION AND CARE OF 40 WOMEN WITH HIGH RISK PREGNANCIES.
DATE/TIME EVENT
CLIENT INITIALS AND GESTATION √ = Consent given to use data
DESCRIPTION OF ‘HIGH RISK’
L- Labour AN- Antenatal PN-Postnatal
D-Delivery
Running Total
23
SUPERVISION AND CARE OF 40 WOMEN WITH HIGH RISK PREGNANCIES.
DATE/TIME EVENT
CLIENT INITIALS AND GESTATION √ = Consent given to use data
DESCRIPTION OF ‘HIGH RISK’
L- Labour AN- Antenatal PN-Postnatal
D-Delivery
Running Total
24
SUPERVISION AND CARE OF 40 WOMEN WITH HIGH RISK PREGNANCIES.
DATE/TIME EVENT
CLIENT INITIALS AND GESTATION √ = Consent given to use data
DESCRIPTION OF ‘HIGH RISK’
L- Labour AN- Antenatal PN-Postnatal
D-Delivery
Running Total
25
LOW RISK LABOURS, BIRTHS WITNESSED OR CONDUCTED.
KEY: L=LABOUR CARE W=WITNESSED BIRTH C= BIRTH CONDUCTED Running total
DATE & TIME OF EVENT/CLIENT INITIALS/ TYPE OF BIRTH √ = Consent given to use data
Category L,W,C
26
LOW RISK LABOURS, BIRTHS WITNESSED OR CONDUCTED.
KEY: L=LABOUR CARE W=WITNESSED BIRTH C= BIRTH CONDUCTED Running total
DATE & TIMEOF EVENT/CLIENT INITIALS/ TYPE OF BIRTH √ = Consent given to use data
Category L,W,C
27
LOW RISK LABOURS, BIRTHS WITNESSED OR CONDUCTED.
KEY: L=LABOUR CARE W=WITNESSED BIRTH C= BIRTH CONDUCTED Running total
DATE & TIME OF EVENT/CLIENT INITIALS/ TYPE OF BIRTH √ = Consent given to use data
Category L,W,C
28
LOW RISK LABOURS, BIRTHS WITNESSED OR CONDUCTED.
KEY: L=LABOUR CARE W=WITNESSED BIRTH C= BIRTH CONDUCTED Running total
DATE & TIME OF EVENT/CLIENT INITIALS/ TYPE OF BIRTH √ = Consent given to use data
Category L,W,C
29
LOW RISK LABOURS, BIRTHS WITNESSED OR CONDUCTED.
KEY: L=LABOUR CARE W=WITNESSED BIRTH C= BIRTH CONDUCTED Running total
DATE & TIME OF EVENT/CLIENT INITIALS/ TYPE OF BIRTH √ = Consent given to use data
Category L,W,C
30
VAGINAL EXAMINATION DATE/ TIME
EVENT CLIENT INITIALS
√ = Consent given to use data
OUTCOME
31
ASSISTING WOMEN USING TENS ASSISTING WOMAN WITH INHALATION ANALGESIA
CARE OF WOMEN WITH EPIDURAL
DATE/TIME OF EVENT
CLIENT INITIALS √ = Consent given to use data
DATE/TIME OF EVENT
CLIENT INITIALS √ = Consent given to use data
DATE/TIME OF EVENT
CLIENT INITIALS
32
IMMEDIATE CARE OF BABIES AT BIRTH ‘TAKING THE BABY’
IMMEDIATE CARE OF BABIES AT BIRTH ‘TAKING THE BABY’
DATE/ TIME OF EVENT
CLIENT INITIALS √ = Consent given to use data
ANTENATAL HISTORY/ TYPE OF BIRTH AND APGAR SCORE
DATE/ TIME OF EVENT
CLIENT INITIALS √ = Consent given to use data
ANTENATAL HISTORY/ TYPE OF BIRTH AND APGAR SCORE
33
IMMEDIATE CARE OF BABIES AT BIRTH ‘TAKING THE BABY’
IMMEDIATE CARE OF BABIES AT BIRTH ‘TAKING THE BABY’
DATE/ TIME OF EVENT
CLIENT INITIALS √ = Consent given to use data
ANTENATAL HISTORY/ TYPE OF BIRTH AND APGAR SCORE
DATE/ TIME OF EVENT
CLIENT INITIALS √ = Consent given to use data
ANTENATAL HISTORY/ TYPE OF BIRTH AND APGAR SCORE
34
EXAMINATION OF THE NEWBORN AT BIRTH DATE/TIME EVENT NO TYPE OF BIRTH & comment CLIENT INITIALS √ = Consent given
to use data
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
35
EXAMINATION OF THE NEWBORN AT BIRTH DATE/TIME EVENT NO TYPE OF BIRTH & comment CLIENT INITIALS √ = Consent given
to use data
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
36
EXAMINATION OF THE NEWBORN AT BIRTH DATE/TIME EVENT NO TYPE OF BIRTH & comment CLIENT INITIALS √ = Consent given
to use data
37
SUBSEQUENT DAILY EXAMINATION OF THE NEWBORN MINIMUM 100
NO. √ =Consent given to use data
DATE HISTORY NO. √ =Consent given to use data
DATE HISTORY
01 26 02 27 03 28 04 29 05 30 06 31 07 32 08 33 09 34 10 35 11 36 12 37 13 38 14 39 15 40 16 41 17 42 18 43 19 44 20 45 21 46 22 47 23 48 24 49 25 50
38
SUBSEQUENT DAILY EXAMINATION OF THE NEWBORN MINIMUM 100 NO. √ =Consent given to use data
DATE HISTORY NO. √ =Consent given to use data
DATE HISTORY
51 76 52 77 53 78 54 79 55 80 56 81 57 82 58 83 59 84 60 85 61 86 62 87 63 88 64 89 65 90 66 91 67 92 68 93 69 94 70 95 71 96 72 97 73 98 74 99 75 100
39
Continuation sheet
NO. √ =Consent given to use data
DATE HISTORY NO. √ =Consent given to use data
DATE HISTORY
40
Continuation sheet NO. √ =Consent given to use data
DATE HISTORY NO. √ =Consent given to use data
DATE HISTORY
41
EXAMINATION AND CARE OF POSTNATAL WOMEN MINIMUM 100
NO. √ =Consent given to use data
DATE HISTORY NO. √ =Consent given to use data
DATE HISTORY
01 26 02 27 03 28 04 29 05 30 06 31 07 32 08 33 09 34 10 35 11 36 12 37 13 38 14 39 15 40 16 41 17 42 18 43 19 44 20 45 21 46 22 47 23 48 24 49 25 50
42
EXAMINATION AND CARE OF POSTNATAL WOMEN MINIMUM 100
NO. √ =Consent given to use data
DATE HISTORY NO. √ =Consent given to use data
DATE HISTORY
51 76 52 77 53 78 54 79 55 80 56 81 57 82 58 83 59 84 60 85 61 86 62 87 63 88 64 89 65 90 66 91 67 92 68 93 69 94 70 95 71 96 72 97 73 98 74 99 75 100
43
Continuation sheet
NO. √ =Consent given to use data
DATE HISTORY NO. √ =Consent given to use data
DATE HISTORY
44
Continuation sheet
NO. √ =Consent given to use data
DATE HISTORY NO. √ =Consent given to use data
DATE HISTORY
45
SUPERVISION AND CARE OF BABIES IN THE NEONATAL UNIT OR TRANSITIONAL CARE DATE
HISTORY DESCRIPTION OF CONDITION √ =Consent given to use data
46
GYNAECOLOGY AND OTHER AREAS
NO. √ =Consent given to use data
CLIENT INITIALS & CONDITION
OUTCOME/CARE GIVEN Record cases of interest that are directly related to childbearing women. Include medical and surgical cases
Example Ectopic Pregnancy Prepared for theatre, post-operative care, pain relief given. Observed discharge advice
47
APPLICATION OF FSE or STAN (YEAR 3)
DATE √ =Consent given to use data
SUPERVISORS SIG.
Induction (Yr 2 & 3)
DATE √ =Consent given to use data
SUPERVISORS SIG.
Theoretical instruction Lecturer: Theoretical
instruction
Lecturer:
Practical 1.
2.
3.
4.
5.
SPECULUM EXAMINATION (not for IOL)
√ =Consent given to use data
SUPERVISORS
SIG.
Theoretical instruction Lecturer:
1.
2.
3.
4.
48
SUTURING OF THE PERINEUM NO. EXPERIENCE DATE EXTENT OF REPAIR √ =Consent given
to use data SUPERVISORS SIGNATURE
1 Theoretical Instruction
1 Practice on Model
2 Practice on Model
1 Supervised Suturing
2 Supervised Suturing
3 Supervised Suturing
4 Supervised Suturing
5 Supervised Suturing
49
Please record any experience that you feel has contributed to you development as a student midwife. For example, water birth or physiological third stage
DATE/TIME OF EVENT
CLIENT INITIALS AND EVENT √ =Consent given to use data
SUMMARY
50