• Records must be factual, consistent and accurate Only approved abbreviations may be used

This is a controlled document. If you are using a printed copy, check it against the guidelines site to ensure you are using the latest edition. Print copies must be destroyed after use.

Abbreviations

This document describes the process for clinical record keeping in the maternity services. This document should be read in conjunction with the Trust’s Clinical Record Keeping Guideline but highlights where the maternity unit process differs from the Trust process.

The Nursing and Midwifery Council regards the making and keeping of records as an essential and integral part of all care given and health professionals should assume that any entries made in a woman’s record will be scrutinised at some point.

All staff must follow the Trust guidelines for record keeping.

The purpose of this document is to ensure a consistent approach to record keeping within the maternity service.

3.1 All entries in the electronic patient record (EPR) must be:

• Records must be factual, consistent and accurate

• Handover notes should not be copied and pasted to avoid including incorrect information handed over.

• Records must be written clearly and documentation should occur at the same time as the event you are recording or as soon as possible afterwards. IT equipment should be made available to all staff to enable them to write records contemporaneously.

• Records must be written contemporaneously unless a clinical emergency prevents this, in which case the record must be completed at the earliest opportunity whilst events are still clear. Any rough notes made contemporaneously should be scanned to media manager on the patient’s record on EPR and must not be destroyed.

• If a late or retrospective entry is made, record it as such by noting ‘retrospective entry’.

• Records must be written in such a manner that any alterations or additions are obvious.

• The language used should be of a professional standard, in terms that the woman can understand. Record factually, giving descriptive, objective information. Do not use jargon, meaningless phrases, irrelevant speculation or offensive subjective statements.

• All safeguarding notes must be written as safeguarding notes and not maternity sensitive notes.

• All women should be encouraged to participate in their maternity care. In order to facilitate this, they will be encouraged to download the My Frimley Health Record app.

• At booking, the midwife should emphasise the importance of downloading the app. Women can share their records with other providers if needed (e.g. if presenting in another hospital) via the app. They can allow access to their records by generating a code and sharing it with the hospital.

• Only approved abbreviations may be used (see “Accepted abbreviations to be used in the maternity department” guideline).

• If care is given by a pre-registration student of midwifery or a maternity care assistant (MCA), all entries that they make in the records should be co-signed by the responsible midwife where possible.

• Community have lone workers and therefore the expectation is that the MCA will have work delegated by the accountable midwife. The MCA documents care given in the EPR and reports back to the midwife.

3.2 Other considerations

• Women with current significant safeguarding concerns and/or significant mental health issues have banners on their EPR. If on the rare occasion, there are additional notes saved anywhere else by the safeguarding teams, a note will be placed in the record to reflect this and advice given as to who you should contact to have access to this information.

• Record relevant conversations with the woman or her family, documenting the entries whenever possible with the involvement, consent and approval of the woman.

• Consultant plans may be written outside clinical encounters. Ensure to check other tabs such as media and letters.

• Always untick the 'hide additional notes' box as these plans may be missed otherwise.

• Document communication between professionals.

• MDT plans are stored under the encounters tab as an 'MDT meeting’. Staff should read and follow any MDT plans.

• If guidelines are not being followed, the rationale of not following the guideline should be clearly documented.

• Where a woman refuses treatment, a careful note should be made of anything that may have been said to the woman about the benefits of the care, advice and any risk factors that have been presented that have aided her decision making.

4.1 Antenatal assessment

At the booking visit, the following should be documented:

• A full obstetric, medical, mental health and social history

• Details of clinical examination

• Presence or absence of allergies, including details of reaction

• Lead professional to be identified

• When referring to ANC, the reason for referral should be clearly documented

• Referrals to other specialties (e.g. smoking cessation, diabetes team)

• Referrals to external services (e.g. domestic abuse support, social services, drug & alcohol support, perinatal mental health services, early help, sure start etc)

• Core Services - Domestic abuse

• Referrals to internal specialities (e.g. Safeguarding, Perinatal Mental Health Midwife)

• On-going plan of care where risk factors are identified

At subsequent antenatal visits:

• Review of known risk factors

• Any safeguarding, mental health risk factors or core service issues

• Details of clinical examination

• Identification of new risk factors and actions taken

• Details of referrals made, including reason and to whom the referral is made

• On-going plan of care and follow up arrangements

• Change of lead professional

• Symphysis fundal height/estimated fetal weight plotted on GROW 2.0

• Review of personalised care plan

4.2 Labour ward management plan

On admission in labour the following should be reviewed and documented:

• Review of known risk factors. Complete the labour risk assessment

• Any safeguarding or mental health risk factors

• History of onset of labour and new risk factors

• Details of clinical examination on admission

• Referrals to obstetrician or other specialties

• Change of lead professional

• A partogram should be started once the woman is in established labour. Populating information on the Labour Progress navigator will automatically populate the partogram (found in the Summary activity)

• Complete the Purpose T risk assessment tool

4.3 Cardiotocograph (CTG) recording

Please refer to the CTG and record keeping section of the ‘Antenatal fetal heart rate monitoring’ and the ‘Intrapartum fetal heart rate monitoring’ guidelines.

4.4 Handover between shifts

The handover of care from one midwife to another should be documented on EPR using the approved template which is in line with the SBAR approach.

4.5 Operation details

All operation/operative details should be documented on EPR.

4.6 Anaesthetic details

All anaesthetic details should be documented on EPR at the relevant section.

4.7 Discharge arrangements

Postnatal care is recorded on EPR until discharge from the care of the community midwife to the health visitor.

Computerised discharge summaries for the mother and the baby (separate summaries) are completed for the community midwife which include details of the birth, known risk factors and any information needed to ensure the woman and baby receive appropriate on-going care. On discharge a clear plan should be documented of any follow up required. A letter is automatically sent to the General Practitioner (GP) via EPIC outlining the treatment given and any medication required. A discharge summary letter is generated on EPIC under the woman’s record for the community midwife. For out of area women, the discharge summary will need to be emailed to the correct hospital.

5.1 CTGs

Women should be register to the MOSOS system to ensure electronic storage of the CTG (WPH site: Labour ward and MAC, FPH site: Labour ward and Antenatal ward). All printed CTGs must be stored in the CTG envelope supplied for this purpose. The envelope must be labelled with the mother’s details. For further details refer to the CTG and record keeping section of the ‘Antenatal fetal heart rate monitoring’ and the ‘Intrapartum fetal heart rate monitoring’ guidelines.

5.2 Storage of existing paper copy documents

Any relevant paper copies the woman may have from care in other trusts (e.g. customised growth chart, scans etc.) must be scanned and uploaded on Media manager on EPR.

5.3 Printed results and reports

Results that are not automatically transferred on EPR, should be documented in the relevant section, e.g., urinalysis results. Paper copies of reports or tests such as ECGs should be scanned and uploaded on Media manager on EPR.

5.4 Antenatal screening and ultrasound results

Ultrasound reports and antenatal screening results will be filed in Imaging or Media on EPR.

Booking bloods and other blood tests (including screening) will be under the Lab results’ tab.

The lead professional is recorded at booking following an assessment of risk factors and discussion of the woman’s wishes.

An assessment of the risk factors, the place of birth and the personalised care plan should be carried out at each appointment and any changes of lead professional should be documented on EPR.

7. Effective January 2026, the Trust will discontinue the provision of physical work diaries. All Community Midwives, Maternity Support Workers, Tobacco Dependency Advisors, NIPE Midwives, and Hearing Screeners are required to use EPIC for scheduling client appointments.

This transition supports the Trust’s commitment to digital integration, improved service coordination, and streamlined record-keeping. Staff are expected to comply with this directive, and appropriate use of EPIC for appointment management will be monitored to ensure consistency and accountability across teams.

To support this change, training and guidance on EPIC usage will be available through the following resources:

• EPIC Helpdesk: For technical issues or login support, contact IT Helpdesk

• User Guides: Step-by-step guides and FAQs are accessible via the Trust intranet under the EPIC Resources section.

• Peer Support: Designated EPIC Champions will be available to offer informal support and answer questions.

8.1 An annual audit of record keeping within the maternity service will be co-ordinated by the lead midwife for audit and quality and will include:

• Basic record keeping standards

Date and time

Use of abbreviations

• Basic clinical note keeping standards

Operation details

Anaesthetic details

Discharge arrangements

Record keeping audit results are presented at the departmental clinical audit meeting. The results of audits/action points are disseminated to all staff.

Process for giving information to women who have communication or language support needs:

Language services

Frimley Health recognises the need to provide interpretative services for women attending for care during pregnancy, labour and birth. Women need access to expert and independent translators. The use of family members and children should be avoided.

The Trust offers telephone and face to face interpreting services on each site that offer over 100 languages 24 hours a day, 7 days a week. GP surgeries may also have this service available. If not, an ID code is available from Antenatal Clinic or Labour Ward, however care must be taken that it is used only for maternity cases. Please follow the process as directed on the Trust Intranet, on the flowcharts in all clinical areas and in the shared maternity drive (Wexham site: maternity safeguarding/interpretation services, Frimley site: interpretation services folder in each clinical area).

Women with hearing problems

British Sign Language (BSL) and Deaf Interpreting Services Sign Solutions are available via a video instant link. Please see shared drive under “maternity safeguarding/interpretation services” for further details at Wexham Park, and interpretation services folder in each clinical area at Frimley Park.

Arrangements can be made for the woman’s carer to stay in the maternity unit with the woman where the carer’s presence is needed to facilitate communication.