Midwifery documentation

One of the biggest challenges for midwives (or any health professional) is documentation. It is vital we thoroughly document all our assessments, actions, and discussions we have with the women we care for. Documentation provides a record for other health professionals, evidence of our care, and it tells a story for women and their families.

The framework I use loosely for clinical documentation is called SOAP:

• Subjective - what the woman feels
• Objective - the woman's symptoms
• Assessment
• Plan

The tension of midwifery documentation
In New Zealand, pregnant women carry their own notes so midwives are not only documenting for professional reasons but they are telling the story of the woman's pregnancy and birth, for the woman and her family. In my experience, this has created a tension in terms of writing style and time. Somehow you have to get a balance between writing in a concise way that makes sense to any health professional you may be referring to. You have to be thorough and detailed so your notes stand up in a court of law in years to come. At the same time, you must write in a way that the woman and her family can understand, which all takes time.

Thinking about my documentation
Over the years I have struggled to write my clinical notes in a family-centred way. I was taught to be short, concise and clinical, and I still follow the format I was taught as a student midwife over 20 years ago - this is to make sure I do not forget anything.

But I found that when I was a Lead Maternity Carer and became part of a woman's life for nearly a year that it was so much easier to take the 'story-telling' approach to writing women's notes - if for no other reason than I had become part of that story.

Writing notes as a locum midwife
My complacency about documentation was challenged last year during my stint as a locum midwife. One woman felt that I didn't write enough details - I didn't do any story-telling, especially when compared to her LMC. This highlighted the difficulty of 'story-telling' when you are making only one or two visits to the woman and family, compared to nine or more months of intimate relationship as primary care-giver.

Future practice
I have become a lot more conscious of what and how I write as a locum midwife. And if nothing else, this feedback has yet again empathized how important details are in documentation, especially when you flit in and out of a woman's life on a temporary basis.

If you are a health professional, what framework do you use for clinical documentation? If you are a health consumer, pregnant mum or patient - especially if you have access to your clinical notes - how do you like to see them written? What do you like to see your health professional write about you?


Image: 'pens' estherase
http://www.flickr.com/photos/78364563@N00/38541060