General Principles of Documentation
The medical record is a sequential record of patient care, a storage place for diagnostic test results, a communication tool for clinicians, and a legal document.
- Include date and time of each encounter (telephone, electronic, and face-to-face).
- Include the diagnostic rationale in the assessment portion of the note.
- Clearly state the plan of care.
- Consent discussions are appropriate to include in the body of a note as well as in a signed form.
- Proofread and correct dictated notes prior to signing.
- Only medical information is appropriate in the medical record; references to legal action, clinical discord, or incident reports are not intended for the medical record.
- Do not obliterate errors, remove pages, or otherwise alter a medical record.
- Patient requests for changes in the medical record should be managed by institutionally approved procedures.
Antepartum, Intrapartum, and Postpartum Medical Records
Each encounter should be documented in the medical record or be retrievable electronically.
The note should include, as appropriate: history, physical, vital signs, test results, assessment, plan, and instructions. Documentation of electronic fetal monitoring (EFM) pattern terminology, pattern recognition, and interpretation should be consistent with current recommendations supported by the National Institute of ChildHealth and Human Development and American College of Obstetricians and Gynecologists.1,2
An antenatal record shall be completed on every obstetrical patient and should be retrievable electronically or via a paper copy. Department of PublicHealth-licensed facilities are required by the Commonwealthof Massachusetts to have a copy of this antenatal record made available in the hospital after 24 weeks of pregnancy.3 If anysignificant changes occur after 24 weeks, the obstetrical providermust send an update to Labor and Delivery. Periodic updatesafter 36 weeks are advised.
For vaginal delivery, completion of the institution’s standarddelivery summary is required. A short note shall be entered in the medical record. In the case of all operativedeliveries (i.e., non-spontaneous vaginal and cesarean), andthose complicated by shoulder dystocia, a dictated operativenote or its electronic equivalent should be completed. This noteshall include the indications and rationale for any procedure ormaneuvers selected.
A printed or electronic copy of any EFM strips and recordedultrasound images is to be maintained as part of the patient’spermanent medical record. If an electronic health record is used,then use only electronic notes (i.e., not handwritten on thepaper strips).
Preservation of EFM Records
Department of Public Health-licensed facilities are required by Massachusetts law4 to keep a record of EFM tracings for at least five years, although 20 years may be appropriate. The tracings shouldinclude the patient’s name and hospital number; date and timeat the beginning of the tracing; and—if delivery concludes themonitoring—date and time of delivery. EFM tracings neednot be stored within the individual patient record, but must bereadily retrievable by the hospital or institution. If electroniccopies of EFM strips are kept, then preservation and storage ofpaper strips is not necessary.
The institution has a responsibility (shared with the medicalstaff) mandated by the Joint Commission to provide adequateresources for record processing, to support quality improvementactivities, and to adhere to record keeping standards includingcompliance with federal regulations (e.g., HIPAA) and itsmandate for a designated institutional compliance officer.
- Macones GA, Hankins GDV, Spong CY, Hauth J, and Moore T. The 2008 National Institute of Child Health and Human Development Workshop report on electronic fetal monitoring update on definitions, interpretation, and research guidelines. Obstet Gynecol. 2008;112:661–66.
- Intrapartum fetal heart rate monitoring: nomenclature, interpretation, and general management principles. ACOG Practice Bulletin No. 106. July 2009, Reaffirmed 2021. American College of Obstetricians and Gynecologists.
- Commonwealth of Massachusetts: Hospital Licensure Regulations. 105 CMR §130 Hospital Licensure, Mass.Gov Available at: http://www.mass.gov/eohhs/docs/dph/regs/105cmr130.pdf - section 130.627.
- Commonwealth of Massachusetts: Hospital Licensure Regulations. 105 CMR §130.370 (B) MGL c111 §70. Page 24. Available at: http://www.mass.gov/eohhs/docs/dph/regs/105cmr130.pdf - section 130.370.
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