A UK midwife was found guilty of misconduct and struck off the Nursing and Midwifery Council register for failing to keep contemporaneous records, she also made similar mistakes with a second patient and failed to record observations and inform colleagues about two others.
"The panel's conclusion is that the registrant's continued registration would represent a serious continuing risk to the safety of patients," it added.
"The panel has decided it is necessary to make an interim suspension order for 18 months, in the public interest and for the protection of the public."
NEW SOUTH WALES, Australia: According to Health Care Complaints Commission dated 07/06/2010, a registered midwife, was found guilty of professional misconduct. The Nurses and Midwives Tribunal of New South Wales said that the midwife's conduct in a home delivery demonstrated a series of serious misjudgments and that she lacked insight into the standards of practice for midwives.
The Nurses and Midwives Tribunal of New South Wales ordered that the midwife should be deregistered for a period of 12 months. The midwife carried out a home delivery involving multiple births which was outside her scope. The midwife only recorded the mother’s vital signs twice during a 13 ½ hour labor and should have called an ambulance shortly after the birth of the baby.
Principles of good documentation: Remember if it is not written it is not done!
Your records need to reflect the care you have provided; it tells a time line account of the care provided to the woman;
NMC Record Keeping for Nurses and Midwives:
Handwriting should be legible.
All entries to records should be signed. In the case of written
records, the person’s name and job title should be printed
alongside the first entry.
In line with local policy, you should put the date and time on all
records. This should be in real time and chronological order,
and be as close to the actual time as possible.
Your records should be accurate and recorded in such a way
that the meaning is clear.
Records should be factual and not include unnecessary
abbreviations, jargon, meaningless phrases or irrelevant
speculation.
You should use your professional judgement to decide what
is relevant and what should be recorded.
You should record details of any assessments and reviews
undertaken, and provide clear evidence of the arrangements
you have made for future and ongoing care. This should
also include details of information given about care
and treatment.
Records should identify any risks or problems that have arisen
and show the action taken to deal with them.
You have a duty to communicate fully and eff ectively with your
colleagues, ensuring that they have all the information they
need about the people in your care.
You must not alter or destroy any records without being
authorised to do so.
In the unlikely event that you need to alter your own or
another healthcare professional’s records, you must give
your name and job title, and sign and date the original
documentation. You should make sure that the alterations
you make, and the original record, are clear and auditable.
Where appropriate, the person in your care, or their carer,
should be involved in the record keeping process.
The language that you use should be easily understood
by the people in your care.
Records should be readable when photocopied or scanned.
You should not use coded expressions of sarcasm or
humorous abbreviations to describe the people in your care.
You should not falsify records.
Remember that your documentation will protect you in a court of law, as it is the only protection you have as often these cases come to court many years later.
