The Perinatal/Combined 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 Combined Perinatal Notes should be completed.

The notes have been developed in line with best practice and are based on the latest evidence and national recommendations. They combine antenatal, intrapartum and immediate postnatal care of the mother, therefore reflecting the complete care episode. The notes place emphasis on patient safety and informed choice.

The notes are designed to be retained in the maternity unit once the mother and baby are transferred to community care. Separate booklets for postnatal care of the baby and community care of the mother will be required to use in conjunction with the Combined Perinatal Notes.

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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