RECORD KEEPINGA Barrister's view

Laura McMahon BL

When might we meet?

Civil claims

Criminal cases

Inquests

Inquiries

NMC hearing

What documents will I ask for?• All midwives notes, however recorded• All medical notes• GP notes• All administrative correspondence• Notes from other patients being cared for at the same time/within

same timeframe• All computer held notes• Woman-held notes• Personnel files as relevant, e.g. previous disciplinary• Midwife expert reports• Letters of complaint relating to similar treatment and/or the same

midwife• Notes of all meetings with woman/family with any and all

healthcare professional• Supervision notes

Midwifery training:

Compassionate

Caring

Patient centred

Empathic

Professional

Accountable

Hierarchical

Barrister training:

Detached

Individualistic

Objective

Analytical

Adversarial

Inquisitorial

Forensic

What I look for in notes:

• Chronological order for all actions• Referrals – not clearly indicated, reviewed and documented• Inconsistency – within midwifery notes and other professional

notes• Failure to cite facts to support statements/findings and care

plans• Failure to give conclusions or base conclusions on the evidence• Failure to document the name of doctor informed of patient

condition• Opinion without facts• Supposition/assumptions without facts or action• Failure to follow a logical order• "Wait and see"• Absence of evidence that info has been given/risks explained• Absence of woman's signature around info/risks/consent

Remember:

• Protect your patient AND your practice

• Assume everything you write or document in any format will be accessed by someone at some stage

• If in doubt, always seek advice within line management or among other healthcare professionals involved in patient care.

• If it’s not recorded it’s not done

• If it's not signed/witnessed it's not done

• Ensure issues around risk and consent are recorded