Poor Record Keeping has Midwife Cautioned

An experienced midwife was cautioned by the NMC for failing to maintain accurate records and then falsified records once she realised she had made an error. The midwife failed to maintain appropriate records which lead to a patient being given the contraceptive drug Depo-Provera while the woman was pregnant. When the midwife realised her mistake and that the patient was pregnant, she falsified the previous entry by adding the words "last menstrual period - first day 11.5.2005" and two weeks later made a further entry - "remembered conversation with patient".

This raises the question of lying to save yourself, however, the fundamental behavior of our nurses and midwives is that of “trustworthiness” that honesty is the best policy – to be dishonest brings our profession into disrepute. Our Codes of Conduct clearly give us guidelines of how to behave and what the expected standards are, this is clearly a breach of these standards.

The ANC did take into account the midwives good record, and that her actions did not result in direct or indirect harm to the patient and the subsequent outcome for the patient was not as a result of her actions. However the committee did find that the inaccuracy of recording and the incidents of falsifying records were not of the standard required of a registered nurse/midwife and resulted in misconduct.

"Nurses are required to adhere to their Code of conduct which says that they should act in a way to uphold the reputation of the profession. The panel considered her behaviour to be unprofessional and dishonest and outside of the NMC's guidelines on record keeping which say that "records should be written in such a manner that any alterations or submissions are dated, timed and signed in such a way that the original entry can still be read clearly".

The midwife had produced good testimonials and that this behaviour was out of character, also the midwife had been dedicated to the profession of nursing and contributed to academic teaching and nurse training.
The report also stated that “last year nearly 10% of the cases that went to a full hearing were to do with poor record keeping”.

Nurses and Midwives need to remember that accurate record keeping is a fundamental part of their practice. Poor sloppy documentation (record keeping) equals a non professional attitude.

Remember if it is not written it is not done!

ref: http://www.medicalnewstoday.com/articles/116988.php