The Diabetes in Pregnancy Notes Exemplar

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The Perinatal Institute has completed a set of notes to support good quality record keeping and aid supervision and training. The scenario is intended to show clinicians how the Diabetes in Pregnancy Notes should be completed.

The CEMACH report reviewing diabetes in pregnancy found deficiencies in standards of record keeping was a common factor associated with poor maternal and fetal outcomes. The report also highlighted deficiencies in communication between groups of professionals and between professionals and women.

It is, therefore, imperative to have a comprehensive document that is evidence based and supports care provision. It should clearly record the care provided, and have prompts to alert professionals to risk factors according to NICE guidelines.

The Diabetes in Pregnancy Notes have been developed in line with best practice and are based on the latest evidence and national recommendations. One of the principle aims is to facilitate a partnership between the principle stakeholders in antenatal/diabetes care – mother, baby and care providers. The notes place emphasis on patient safety and informed choice. The notes are designed to facilitate comprehensive history taking, promote effective communication between the mother and the multi-disciplinary care team.

The notes are hand held by the expectant mother, this approach encourages two-way communication so the expectant mother and her family are fully informed and able to contribute to the decision making process. All clinical care and management plans are documented within the hand held record encouraging openness and transparency. Effective communication within the multi-disciplinary team helps to prevent avoidable loss and accurate, contemporaneous record keeping is a fundamental component of good maternity practice.

For further information, please contact the specialist midwives at the Perinatal Institute:

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