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1 Gloucestershire Hospitals NHS Foundation Trust TRUST NON CLINICAL POLICY MATERNITY SERVICES HEALTH RECORDS B0556 Any hard copy of this document is only assured to be accurate on the date printed. The most up to date version is available on the Trust Policy Site. All document profile details are recorded on the last page. All documents must be reviewed by the last day of the month shown under review date, or before this if changes occur in the meantime. FAST FIND: AC1 PROCESS FOR ACCESS TO PREVIOUS HEALTH RECORDS AND AMALGAMATION OF MATERNITY RECORD INTO ONE FOLDER AND MANAGEMENT OF MATERNITY HEALTH CARE RECORDS AND MATERNITY HAND HELD RECORDS. AC2 GUIDELINES FOR FILING DOCUMENTATION INTO THE MATERNITY HEALTH RECORDS (AGREED STORAGE ARRANGEMENTS) DOCUMENT OVERVIEW: The aim of this policy is to inform all staff about the procedural arrangements, management of maternity services health records, as well as the clinical record keeping standards required within maternity services. This includes maternity hand held records (carried by women) and the maternity health records (stored within a hospital setting) and any electronic health record. This document may be made available to the public and persons outside the Trust as part of the Trust s compliance with the Freedom of Information Act 2000 MATERNITY SERVICES HEALTH RECORDS POLICY B0556 v4 PAGE 1 OF 10

2 Gloucestershire Hospitals NHS Foundation Trust MATERNITY SERVICES HEALTH RECORDS 1. INTRODUCTION 2. DEFINITIONS 3. PURPOSE 4. ROLES AND RESPONSIBILITIES 5. PROCEDURAL ARRANGEMENTS FOR RECORD MANAGEMENT 6. PROCEDURE FOR ACCESSING CURRENT MATERNITY HEALTH RECORDS 7. PROCEDURE FOR ACCESSING PREVIOUS MATERNITY AND MEDICAL RECORDS 8. OTHER ASPECTS RELATED TO MATERNITY HEALTH RECORDS 9. BASIC RECORD KEEPING STANDARDS 10. ARRANGEMENTS FOR DOCUMENTING THE NAME OF THE LEAD PROFESSIONAL 11. MATERNITY CLINICAL RECORD KEEPING STANDARDS 12. STORAGE ARRANGEMENTS 13. TRAINING 14. MONITORING OF COMPLIANCE 15. REFERENCES ACTION CARDS AC1 PROCESS FOR ACCESS TO PREVIOUS HEALTH RECORDS AND AMALGAMATION OF MATERNITY RECORD INTO ONE FOLDER AND MANAGEMENT OF MATERNITY HEALTH CARE RECORDS AND MATERNITY HAND HELD RECORDS. AC2 GUIDELINES FOR FILING DOCUMENTATION INTO THE MATERNITY HEALTH RECORDS (AGREED STORAGE ARRANGEMENTS) MATERNITY SERVICES HEALTH RECORDS POLICY B0556 v4 PAGE 2 OF 10

3 Resources Review/ Monitoring Implementation Records Reporting 1. INTRODUCTION 1.1 The aim of this policy is to inform all staff about the procedural arrangements, management of maternity services health records, as well as the clinical record keeping standards required within maternity services. This includes maternity hand held records (carried by women) and the maternity health records (stored within a hospital setting) and any electronic health record. 1.2 Documentation is to be maintained at a high standard and contemporaneous nature. Where additional resources are available, i.e. approved stickers or proformas, best practice would be to utilise these methods for documentation. However if the approved document is unavailable and/or the contents of the approved document are fully documented in the health records; this will be considered sufficient. 2. DEFINITIONS 2.1 Health Record The term health record is defined by Section 68 of the Data Protection Act 1998, and means any record which consists of information relating to the physical or mental health or condition of an individual, and has been made by or on behalf of a health professional in connection with the care of that individual. 2.2 The maternity hand held record is the record carried by the woman detailing her current pregnancy 2.3 The maternity health record is the confidential file which is stored in the hospital setting 3. PURPOSE The purpose of this guideline is to ensure consistent practice with health records management and documentation. 4. ROLES AND RESPONSIBILITIES Post/Group Details Named Midwife following this and associated policies/procedures utilise the information within this guideline to provide the best evidence and practice Midwives following this and associated policies/procedures utilise the information within this guideline to provide the best evidence and practice Medical Staff following this and associated policies/procedures utilise the information within this guideline to provide the best evidence and practice x x x x x x x x x Specialist Midwife following this and associated policies/procedures utilise the information within this guideline to provide the best evidence and practice Maternity Documentation Group Monitoring effectiveness of policy x Gloucestershire Obstetric Guideline Group Approval and Ratification x 5. PROCEDURAL ARRANGEMENTS FOR RECORD MANAGEMENT (see action card AC1) 5.1 Throughout the county, booking for maternity care takes place either in the home or GP surgery / Antenatal Clinic (ANC) where details of previous maternity and general medical episodes are taken verbally. At booking women will be given their maternity hand held records to keep throughout MATERNITY SERVICES HEALTH RECORDS POLICY B0556 v4 PAGE 3 OF 10

4 pregnancy. In the rare event of there being concern regarding the ability of the women to retain the health record, or if the woman does not wish to carry her records, it will be kept within the antenatal clinic. 5.2 Where previous maternity and medical history is identified the previous records must be located. 5.3 Women s details are passed to staff in the relevant maternity unit either to book a scan and make up the maternity health records (CGH, GRH), or just make up the maternity health records (Stroud). If the patient has been treated previously within Gloucestershire hospital NHS Foundation Trust, the existence of other medical or maternity records will be identified within the PAS system. 5.4 Previous health records held should be obtained in advance of any first consultation and any subsequent consultation if required by doctor or midwife. 5.5 Where each maternity episode is contained in separate health records the previous maternity health record will be obtained in order to amalgamate all maternity health records into one health record this will ensure a single continuous maternity record is achieved. A second volume can be added or started if the health records are too large for amalgamation. 5.6 All women should be entered on the PAS system at time of booking. If no previous maternity health record exists a new record should be raised using the MAT number so that the number can be traced. 5.7 All maternity health care records must be traced on the electronic PAS tracing system using the MAT prefix whenever they are retrieved and moved to a different area, to enable tracking of the health care records. 6. PROCEDURE FOR ACCESSING CURRENT MATERNITY HEALTH RECORDS 6.1 Maternity health care records of women who are currently pregnant or have delivered and are still under the care of the community midwives are available 24 hours a day in the antenatal clinic GRH by contacting the ANC reception staff GRH on Maternity Health Care records are stored at the site of booking and then transferred to the place of booking one month prior to EDD Out of office hours Maternity records may be obtained by going to ANC. Verification of identity and reason for those requiring health records will be ascertained by those members of staff authorising the release of the records. 7. PROCEDURE FOR ACCESSING PREVIOUS MATERNITY AND MEDICAL RECORDS (see action card AC1) 7.1 Previous Maternity Records held in County Recently active maternity records will be archived within the Women s Centre record store at GRH or at SMU but older maternity records will be stored off site with an external provider. Records stored off site at Crown or Squirrel can be obtained through ANC reception staff (Gloucester, Cheltenham or Stroud) Requests for maternity records in any of the record stores are accessed by ANC staff usually by using their PAS tracer menu, the requests may be put through on a pulling list to health records printer 1421(Gloucester) or printer 466 when in Cheltenham. Alternatively ring medical records at GRH directly. 7.2 Access to General Medical Records When previous general medical records are required, records can be requested via a pulling list to health records printer 1421(Gloucester) or printer 466 when in Cheltenham. 7.3 Out of Hours (After 22.00) General health records for CGH or GRH may be obtained by contacting the site Lead Nurse/Night Sister/Charge Nurse in accordance with the Trust Procedure for Retrieving Records out of Hours MATERNITY SERVICES HEALTH RECORDS POLICY B0556 v4 PAGE 4 OF 10

5 GRH Bleep 2345 CGH Bleep Accessing Records out of County If previous treatment out of county is identified verbally, then if required the records or a case summary will be requested by the Consultant Obstetrician. 8. OTHER ASPECTS RELATED TO MATERNITY HEALTH RECORDS 8.1 Information Sharing The principle of access to patient information for care management should always be applied and carried out in the best interests of the patient when considering whether health care records should be transferred and information shared. All access to information within the NHS is governed by strict information sharing principles. Refer to GHNHSFT BO413 Information Governance Policy GHNHSFT RD2 Information sharing Principles). In line with PIAG (England) approval (2009) it has been deemed acceptable for records to be viewed as part of the NHSLA assessment process. 8.2 When individuals require copies of their personal health record regarding their care within The Women s and Childrens Division, they should be advised to contact the Access to Medical Records Office for the relevant documentation and details of the costs involved. 8.3 Transfer of Maternity Health Records to Other Hospitals For transfers in county the original health records may be sent either in a sealed envelope with the professional escort, or where appropriate with the patient using a sealed orange bag or in an official blue medical records bag on hospital transport All health records must be traced electronically when transferred from one area to another Health records should not leave the county unless under exceptional circumstances. If required out of County, all health records should be photocopied and this copy provided to the receiving unit. 9. BASIC RECORD KEEPING STANDARDS 9.1 Process for ensuring a contemporaneous, complete record of care To ensure there is a complete and contemporaneous record of the care all women receive, consultations and admissions should be recorded in one place, usually the maternity hand held record. These records should demonstrate continuous and accurate updating during periods of admission. All retrospective entries should be clearly identifiable When women are seen at a hospital based clinic, an entry is made into the Maternity Health Care Record All professions who advise treat or care for women should record this information in chronological order to ensure that a full and accurate picture of the care received is kept with the women. This applies particularly where care is shared across the community and acute services and between professionals Allied health professions such as physiotherapists, when giving advice and treatment on an outpatient or inpatient basis must record such advice and treatment in the maternity hand held health records. MATERNITY SERVICES HEALTH RECORDS POLICY B0556 v4 PAGE 5 OF 10

6 9.1.5 Only sensitive information which the woman may not wish included in the hand held health record or information awaiting filing in the hand held health record should be kept in the maternity health record When an approved documentation proforma or sticker is available, best practice is to use this method for documentation. However if the contents of the sticker or proforma are documented specifically in the records; this will be considered sufficient. 10. ARRANGEMENTS FOR DOCUMENTING THE NAME OF THE LEAD PROFESSIONAL 10.1 At booking, a risk assessment should be completed by the midwife, and based on this a lead professional should be recommended for the woman s care. This should be clearly documented in the hand held notes, and the computerised records. Should there be a change in the lead professional at any time during the pregnancy or labour, this should be clearly documented on the front cover of the Maternity Hand Held Record and the computerised records by the midwife responsible for that episode of care. (Refer to GHNHSFT Routine Antenatal Care Including Criteria and Guidance for Place of Birth and Choice of Lead Professional) 11. MATERNITY CLINICAL RECORD KEEPING STANDARDS 11.1 Basic clinical record keeping standards that must be adhered to: All entries must be in indelible ink Handwriting must be clear and legible Records must demonstrate continuous and accurate updating Every entry into the handheld or hospital record should be dated, timed and signed The professional responsible for the episode of care must be clearly identifiable by printed name and signature and designation Any errors should be crossed out with a single line and signed Any abbreviations used should be from the approved list see related document 1 (RD1) Any blank spaces in the records prior to the last entry should be crossed out with a single line The computer record must match the hand written record The patient identification number and /or date of birth must be recorded on every page The records must show when the second midwife or doctor was called to attend the delivery and when they arrived All retrospective entries should be clearly defined 11.2 Basic Clinical Note Keeping Standards: antenatal assessment labour ward management plan cardiotocograph recording operation details anaesthetic details discharge arrangements 12. STORAGE ARRANGEMENTS (see action card AC2) 12.1 The Maternity health care record is divided into 6 clear sections headed as follows: Clinical record Correspondence Investigations Charts and forms Professional records Legal documentation 12.2 All documentation must be filed within speciality in chronological order. MATERNITY SERVICES HEALTH RECORDS POLICY B0556 v4 PAGE 6 OF 10

7 12.3 Results and reports from previous pregnancies should be stored securely in the result section of the relevant pregnancy All records, charts, results and reports should be filed in the Maternity health care records and must be stored as stipulated in action card AC Under no circumstance must there be any loose documentation Wherever possible test results should be written in the hand held records. Loose leaf test results and scan reports and other information should be kept to a minimum in the maternity hand held records and glued or attached securely with a plastic treasury tag FBS and/or cord ph results and reports are to be written/secured contemporaneously within the hand held records and in the Neonatal Health Care Record On Admission / Discharge The Maternity hand held health record should be inserted into the Maternity health record and all information pertaining to care should be filed in the same record whilst the woman is in hospital. However, antenatal patients should be in possession of their complete hand held health record on discharge from hospital to enable continuity of care and treatment in the community except where sensitive information exists Telephone Advice slips (Antenatal and postnatal) Where possible these should be filed in the maternal healthcare record. However, it is permissible for them to be securely attached to the maternity hand held care record prior to them being hole punched and amalgamated into the correspondence section ( in chronological order) of the maternity health care record Only the orange maternity hand held records excluding pink birth notes should accompany the woman home following delivery Where women have delivered in another Trust or hospital and antenatal and post natal care only is being provided by Trust staff the record accompanying the women should be returned to the hospital in which the delivery took place Unavailable Hand Held Records On the rare occasion in which a woman does not have the maternity hand held health record available for an antenatal consultation, a written summary of the clinical assessment should be made on a separate clinical record sheet. This should be handed to the woman for inclusion in the maternity hand held health record and a copy made for entry into the maternal health care record if they are not available. An entry should be made in the electronic GP record or hospital record depending on where the consultation takes place Returning Hand Held Records At transfer to the community the woman will take home with her the orange Hand Held Maternity Records and discharge letter (STORK) outlining the type of delivery, care given in hospital and any ongoing care requirements for mother and baby It is imperative that these hand held health records held by women are returned to the delivering hospital to be incorporated into the Maternity health care record at the end of the maternity episode. It is the responsibility of the community midwife discharging the woman and her baby to Health Visitor care to ensure that any maternity hand held health records are returned within one week to a point identified locally at Gloucestershire Royal Hospital for attention by administrative staff. MATERNITY SERVICES HEALTH RECORDS POLICY B0556 v4 PAGE 7 OF 10

8 12.9 Completed Maternity Health Records In all cases following delivery, maternity health care records will initially be stored at Gloucestershire Royal Hospital or Stroud Maternity Unit. Subsequently they will be archived in offsite storage currently provided by Cintas (previously known as Squirrel) storage. 13. TRAINING Dissemination of policy when approved. 14. MONITORING OF COMPLIANCE 14.1 This list is not exhaustive and additional criteria may be included at the Trust discretion 14.2 The audit will include the current Maternity quality standards and sample size if related 14.3 Sample sizes selected will be dependent on the cohort size. The data collection period will be identified by the Maternity Audit Lead 14.4 Action plans will be developed and reviewed as required by the instigating body 14.5 The audit will be carried out using the standardised audit tool and methodology as agreed by the maternity audit team and in line with the audit process The audit results will be presented to the multidisciplinary Obstetrics and Gynaecology Audit presentation meeting Where deficiencies are identified, an action plan will be developed by the author, following the Multidisciplinary Obstetrics and Gynaecology Audit presentation meeting. These action plans are implemented and monitored by the Associated Forum Audits are undertaken as routine triennially, however if deficiencies are identified or changes implemented, audit will be undertaken sooner. 15. REFERENCES Audit Commission (1995) Setting the Records Straight/Study of Hospitals Medical Records, HMSO Publications Audit Commission (1999) Setting the Record Straight: A Review of Progress in Health Records Services. ISBN Department of Health (2006) Records Management NHS Code of Practice Parts 1 and 2 The Data Protection Act 1998 GHNHSFT (2008) Criteria and Guidance for Place of Birth and Midwifery Led Care Gloucestershire Hospitals NHS Foundation Trust. Records Management Policy Statement and Strategy, Gloucestershire Hospitals NHS Foundation Trust, January 2007 MATERNITY SERVICES HEALTH RECORDS POLICY B0556 v4 PAGE 8 OF 10

9 MATERNITY SERVICES HEALTH RECORDS DOCUMENT PROFILE DOCUMENT PROFILE REFERENCE NUMBER CATEGORY B0556 Non Clinical VERSION 4 SPONSOR AUTHOR Vivien Mortimore Eleanor Sonmezer ISSUE DATE February 2015 REVIEW DETAILS February 2018 ASSURING GROUP APPROVING GROUP APPROVAL DETAILS DISSEMINATION DETAILS Maternity Newborn Clinical Forum Gloucestershire Obstetric Guideline Group (GOGG) November 2004 GOGG May 2005 GOGG 06/11/2007 item GOGG 30/01/2008 Health Records Committee 28/08/2008 item 10 Maternity Clinical Governance 08/09/2008 Health Records Committee 20/01/2009 item 209 GOGG 10/02/2009 item 9a Clinical Policy Group 12/03/2009 item 40/09 20 Senior Nurse Committee 06/12/2011 item GOGG Upload to Policy Site; cascaded via Women and Children s Division EQUALITY IMPACT ASSESSMENT Added to policy 20/01/2009 KEYWORDS RELATED TRUST DOCUMENTS OTHER RELEVANT DOCUMENTS Health Records, Maternity Services, filing Routine Antenatal Care Including Criteria and Guidance for Place of Birth and Choice of Lead Professional Clinical Records Keeping Policy AC1 Process for Access To Previous Health Records and Amalgamation of Maternity Record Into One Folder And Management of Maternity Health Care Records And Maternity Hand Held Records. AC2 Guidelines for Filing Documentation Into the Maternity Health Records (Agreed Storage Arrangements) Authors Version Reason for review Ratified Practice Development Midwife Version 1 Written November 2004 Minor amendment May 2005 New guideline Gloucestershire Obstetric Guideline Group (GOGG) Practice Development Midwife Practice Development Midwife Version 2 Review November 2007 Minor amendment May 2009 Version 3 Review December 2011 Triennial review Review following introduction of new hand held records Gloucestershire Obstetric Guideline Group (GOGG) Gloucestershire Obstetric Guideline Group (GOGG) Practice Development Midwife Version 4 February 2015 Triennial review Gloucestershire Obstetric Guideline Group (GOGG) MATERNITY SERVICES HEALTH RECORDS POLICY B0556 v4 PAGE 9 OF 10

10 Gloucestershire Hospitals NHS Foundation Trust EQUALITY IMPACT ASSESSMENT INITIAL SCREENING 1. Lead Name: Kirsty Davis Job Title: Practice Development Midwife 2. Is this a new or existing policy, service strategy, procedure or function? New Existing 3. Who is the policy/service strategy, procedure or function aimed at? Patients Carers Staff Visitors Any other Please specify: 4. Are any of the following groups adversely affected by this policy: If yes is this high, medium or low impact (see attached notes): Disabled people: No Yes Race, ethnicity & nationality: No Yes Male/Female/transgender: No Yes Age, young or older people: No Yes Sexual orientation: No Yes Religion, belief & faith: No Yes If the answer is yes to any of these proceed to full assessment. If the answer is no to all categories, the assessment is now complete. Date of assessment: Signature: Director: Completed by: Kirsty Davis Job title: Signature: This EIA will be published on the Trust website. A completed EIA must accompany a new policy or a reviewed policy when it is confirmed by the relevant Trust Committee, Divisional Board, Trust Director or Trust Board. Executive Directors are responsible for ensuring that EIA s are completed in accordance with this procedure. MATERNITY SERVICES HEALTH RECORDS POLICY B0556 v4 PAGE 10 OF 10

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