Learning objectives

Participants are able to write down midwifery records in English (C4, A3)

Indicators
1. Participants are able to write a paragraph, a topic sentence, supporting sentence,
conclusion, essay, an introductory paragraph, writing body of paragraph, and conclusion.
2. Participants are able to understand many kinds of midwifery form from different country.
3. Participants are able to write down the midwifery record in different midwifery cases using
the international form.
 Midwifery Record
Definition
Midwifery record is a document that provide evidence of a midwife's involvement with a
woman and baby.

The Purpose Of Record-Keeping

The primary purpose of keeping records is to have an account of the care and treatment given
to a woman and baby. As well as their clinical function, records have an important legal
purpose. Records provide evidence of a midwife's involvement with a woman and baby. They
need to be sufficiently detailed to demonstrate that the midwife has discharged his or her duty
of care.

The Nursing and Midwifery Council's revised Code (NMC, 2015) imposes a duty on midwives
to keep clear and accurate records relevant to their practice. To discharge the duty set out in
standard 10 of the Code, midwives must show that they:
1. Complete all records at the time or as soon as possible after an event, recording whether
the notes are written sometime after the event
2. Identify any risks or problems that have arisen and the steps taken to deal with them, so
that colleagues who use the records have all the information they need
3. Complete all records accurately and without any falsification, taking immediate and
appropriate action if you become aware that someone has not kept to these requirements
4. Attribute any entries you make in any paper or electronic records to yourself, making sure
they are clearly written, dated and timed, and do not include unnecessary abbreviations,
jargon or speculation
5. Take all steps to make sure that all records are kept securely
6. Collect, treat and store all data and research findings appropriately.

In this section we will learn different kind of midwifery record form from many countries over
the world, including:
1. British Columbia Antenatal Record from The United Kingdom
2. Pregnancy Record from Queensland, Australia
3. Emergency Hormonal Contraception Record from the United Kingdom.
4. Normal Birth Package from Ontario, Canada.

Midwifery Assignment
Please fill the form using your current data from your patient. Fill the document using online
pdf filler such as https://www.docfly.com/pdf-form-filler.
The record form used:
1. Pregnancy Record from Queensland, Australia.
2. Normal Birth Package from Ontario, Canada.
Reference
British Columbia Antenatal Record Parts 1 and 2. Retrieved from
http://www.perinatalservicesbc.ca/Documents/Form/Antenatal-Record-1-and-2.pdf
Griffifth, Richard. 2016. Keeping Accurate Record. British Journal of Midwifery. Volume 24.
Issue 8. ISSN (print): 0969-4900. ISSN (online): 2052-4307. Retrieved from
https://www.britishjournalofmidwifery.com/content/legal/keeping-accurate-records
NHS Wales. Emergency Hormonal Contraception Record Form. Retrieved from
http://www.cpwales.org.uk/getattachment/Contract-support-and-IT/Contractual-
Framework/Enhanced-Services/EHC/Record-Form.pdf.aspx?lang=en-GB
Pregnancy Health Record. Retrieved from
https://clinicalexcellence.qld.gov.au/sites/default/files/docs/clinical-
pathways/pregnancy-health-record.pdf
The Association of Ontario Midwives. 2021. Clinical Record Forms: Normal Birth Package.
Retrieved from https://www.ontariomidwives.ca/clinical-record-forms.