Maternity Notes Exemplars


The Perinatal Institute has completed a set of booklets to complement the use of maternity notes that we produce, to support good quality record keeping. Good record keeping is an integral part of midwifery practice, and is essential to the provision of safe and effective care.

Nursing and Midwifery Council – The Code. Professional standards of practice and behaviour for nurses for midwives. March 2015.

National audits have demonstrated that poor record keeping is associated with adverse outcomes. Good record keeping has many important functions such as:

  • Help improve accountability.
  • Demonstrating how decisions related to patient care were made.
  • Supporting the delivery of services and documented evidence.
  • Supporting effective clinical judgements and decisions.
  • Supporting patient care and communications.
  • Making continuity of care easier.
  • Promoting better communication and sharing of information between the members of the multi professional healthcare team.
  • Helping to identify risks, and enabling early detection of complications.
  • Supporting clinical audit, research, allocation of resources and performance planning.
  • Helping to address complaints or legal processes.

Principles of good record keeping

Keep clear and accurate records relevant to your practice. This includes but is not limited to patient records. It includes all records that are relevant to your scope of practice.

To achieve this, you must:

  • Complete all records at the time or as soon as possible after an event, recording if the notes are written sometime after the event.
  • 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.
  • 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.
  • 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.
  • Take all steps to make sure that all records are kept securely.
  • Collect, treat and store all data and research findings appropriately.

View the exemplars:

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