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.

1. Include date and time of each encounter (telephone, electronic, and face-to-face).
2. Include the diagnostic rationale in the assessment portion of the note.
3. Clearly state the plan of care.
4. Consent discussions are appropriate to include in the body of a note as well as in a signed form.
5. Proofread and correct dictated notes prior to signing.
6. 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.
7. Do not obliterate errors, remove pages, or otherwise alter a medical record.
8. 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 Child Health 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 paper copy maintained in the medical record. Department of Public Health-licensed facilities are required by the Commonwealth of Massachusetts to have a copy of this antenatal record made available in the hospital after 24 weeks of pregnancy.³ If any significant changes occur after 24 weeks, the obstetrical provider must send an update to Labor and Delivery. Periodic updates after 36 weeks are advised.

For vaginal delivery, completion of the institution’s standard delivery summary is required. A short written note shall be entered in the medical record. In the case of all operative deliveries (i.e., non-spontaneous vaginal and cesarean), and those complicated by shoulder dystocia, a dictated operative note or its electronic equivalent should be completed. This note shall include the indications and rationale for any procedure or maneuvers selected.

A printed or electronic copy of any EFM strips and recorded ultrasound images is to be maintained as part of the patient’s permanent medical record. If an electronic health record is used, then use only electronic notes (i.e., not handwritten on the paper 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 (CRICO recommends 20 years). The tracings should include the patient’s name and hospital number; date and time at the beginning of the tracing; and—if delivery concludes the monitoring—date and time of delivery. EFM tracings need not be stored within the individual patient record, but must be readily retrievable by the hospital or institution. If electronic copies of EFM strips are kept, then preservation and storage of paper strips is not necessary.

Institutional Responsibility

The institution has a responsibility (shared with the medical staff) mandated by the Joint Commission to provide adequate resources for record processing, to support quality improvement activities, and to adhere to record keeping standards including compliance with federal regulations (e.g., HIPAA) and its mandate for a designated institutional compliance officer.

1. 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.
2. Intrapartum fetal heart rate monitoring: nomenclature, interpretation, and general management principles. ACOG Practice Bulletin No. 106. July 2009, Reaffirmed 2017. American College of Obstetricians and Gynecologists.
3. 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.
4. 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.