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Closed Public Consultation: Record Keeping Standard for Midwives

About this consultation

The College’s commitment to risk-based regulation requires a rigorous approach to policy development. This means revisions to the College’s policies and standards must be based on numerous factors including an evaluation of risks of harm, research evidence, and an analysis of options and impacts. This process ensures that our regulatory tools are not adopted as the default solution but are introduced to mitigate risk when other non-regulatory options are unable to deliver the desired results.

Consultation with midwives, midwifery and regulatory organizations, and the public is an essential part of our policy development process, and in keeping with our guiding principles of accountability and transparency.

Background

The College’s current Record Keeping Standard for Midwives was last updated in 2013 and is in need of updating. The standard contains details that are no longer relevant and expectations that are not achievable when documenting in electronic medical records. The standard is also missing details required to ensure the midwifery record contains a complete picture of the client’s care. The Record Keeping Standard has been in revisions for almost a year to ensure it reflects the context of midwifery. It is now ready to be reviewed during this public consultation.

Key revisions

The changes to the Record Keeping Standard for Midwives are intended to update its content and provide enough information for midwives to understand what their responsibilities are to document in, and maintain, the client record. The main revisions to the standard are listed below: 

  • Definitions of the midwifery record and the hospital record have been added
  • The requirement that records must be in French or English has been added
  • The details about specific records (i.e., the Ontario Antenatal Record) have been removed
  • The standards are achievable for documenting in electronic medical records and paper records
  • Efforts were made to minimize duplication of records. For example, the proposed standard does not require that the antenatal records be filled out completely if the information is contained elsewhere in the midwifery record
  • The standard clearly identifies practice owners as the information custodians responsible for record management
  • The standards about client confidentiality and client access to records have been removed because this information is held in the Personal Health Information and Privacy Act (PHIPA).
  • The “Guideline on Records” section has been removed because it does not set a minimum standard

Consultation request

Consider: 

  1. Are the proposed requirements clear?
  2. Are risks of harm to the public addressed? For example, does the standard have sufficient detail that a complete picture of the client’s care is documented?
  3. Is the standard achievable for all midwives?
  4. Is there anything missing?

Current standard for reference

How to provide feedback

You may submit your comments on this page below.

All comments are reviewed before being posted publicly to ensure they meet the Posting Guidelines. Your name and email will not be published with your feedback, however, you will be identified as a member of the public, a midwife, or a stakeholder. Email addresses are required to ensure that individuals provide feedback only once. If you prefer to provide feedback using a different format, including email, or if you have any questions about the consultation, please contact us as qac@cmo.on.ca

This consultation is open until Thursday, August 4, 2022.

All Feedback

  1. I don’t agree that the “midwifery record serves as a key form of communication”. It may never be used to communicate with anyone. It needs to stand alone as the story of the client’s care and accurately reflect what occurred, when and by whom.
    Realize OHIP number is used as an example of an identifier (“such as”) however it may be more reflective of the opportunity to care for uninsured clients if “ie” is used – as is for the contact information
    I also agree that often consult letters or results from other care providers are not always provided even upon multiple requests so possibly some mention that if they can not be obtained, notation is made of the attempts etc.
    I also feel clients can decline tests etc., and that we have always differentiated that from refusal. So 9 j) could say “consent, declination or refusal”

    • The current OPR has check boxes for various informed choice discussions ie FM, pain management. How does one meet the standard for date, initials and discussion content if using these standard checkboxes?

      Also receiving summaries after consultation is very inconsistent. As another person noted, sometimes client report is the only information available to the midwife.

      • Standards:
        1./2. I would like to know the minimum # of identifiers. I was always taught there should be at least 3.
        3. There is an unnecessary period beside the word “overall”. I don’t feel this statement is reflective or supportive of shared-care models. It would be clearer to me to state that it is recognized midwives may work in team models. In all models of care, there should be one midwife assigned to each client who is responsible for overseeing each client’s care. This person must be clearly identified on the client’s record.
        4. This isn’t clear to me-does this mean outside of the physical practice location? By another care provider? Please clarify.
        6. I think it is impossible to know what all care providers know. Do I expect an anesthesiologist to know what AMTSL is an abbreviation of? No, but I do for those it is pertinent and expect someone to clarify if they are unfamiliar. It may be clearer to recommend avoiding any abbreviations that may be unclear to those within the circle of care. Or to recommend avoiding them all together-though I doubt that would be followed.
        7. There is not room for a signature at the end of antenatal entries on the OPR. Can this be changed to initials?
        9. j. I thought that previously if there was a refusal of care that was outside of standard of care, or posed a significant risk to the client/fetus/infant, documentation surrounding the client’s reasoning and our response was required. This is not reflected in this statement. It may be a good idea to link the guideline addressing this if it’s not going to be explicitly stated here. I also believed that we were able to state we had discussed the ICD for X-topic per the practice policy on that topic. This may also help in-terms of midwives implementing this standard into practice.
        n. How does one identifying a check-box as a duplicate? This is unclear.

        Thanks!

        • I read this a while ago and got the impression that there was a suggestion that all of the requisitions used on a client had to be preserved. This seems to not make sense once the results are in the chart.

          • The midwifery record must include a summary of any prenatal, intrapartum, postpartum, or newborn care provided to the client outside of the midwifery practice group.—–this may not always be achievable for care provided prior to coming into RM care

            when working with templates or checkboxes, an initial and date must accompany each checkbox or field to correspond with when the care was provided.—-The OPRs do not allow for signature & date on the included checklist when documenting in Telus EMR PSS

            • I found this regulation too superficial as many points are not addressed considering the contemporaneous ecosystem in health care. I believe that this regulation needs professional assistance from enterprise risk management (ERM) and high-reliability organizations (HRO) experts.
              Have you seen the CNO or the CPO documentation standards? There are detailed and offer some help for the members. You must provide links to the insurance and evidence-based information for the members to follow and learn.
              The goal of the midwifery record is to “tell the story” of the client’s health care journey to the client, other providers, researchers and auditors. As such, midwifery documentation in the record must be divided into a detailed summary, clinical notes, and telephone and electronic communications with clients.
              It might follow a subjective, objective assessment plan (SOAP) methodology of encounter for others to understand the course of actions of every client encounters.
              You are not offering tools or recommendations like flow sheets as record-keeping tools that can assist midwives in documenting and tracking important clinical information over time. Flow sheets may permit midwives to quickly see trends, which enhances their ability to identify the appropriate treatment, easily retrieve data, and support continuity of care.
              What about pre-populated templates in EMR? How to ensure that pre-populated records are accurate?
              What about transitions of care documentation standards?
              What about referring midwives’ mechanism to track referrals documentations when another clinician has to provide care to monitor whether referrals are being received and acknowledged? What about a sense of the urgency in the documentation of the consultation?
              What about cyber security?
              To protect the public, you must support your members to comply with legislation.

              • Number 4 is unclear to what degree a midwife is responsible for a)being fully aware of care that is sought/accessed outside of the MPG and b)accurately summarized. I think this should be defined “to the best of the midwives knowledge” as we rely on the word of the client and any records received to create this picture. Also if the entire record is accessed it would be redundant to also summarize. Ie; a consult note from a Pediatrician cardiologist saying no further follow up needed does not need to be double charted.

                Number 9 N also feels unnecessarily difficult for midwives to hold themselves to. For example if a discussion about preterm labour has been clearly documented with date and signature in the OPR but is also an option on a check list, even if the rest of the checklist is used and it is left blank the OPR should still provide evidence enough that the discussion was had.

                • saying that the record is for the benefit of the client. Are you sure?…. the person is going through a life changing process and read about clinical facts and measures and discussions subjects. The person is under surveillance mechanisms but where can we see traces of accompaniment?

                  we read about what a midwife did but can we learn about what is midwifery? can record serve also to illustrate the midwifery identity? more than measures, facts and dates… any narrative? words used by the woman/person?

                  I would expect:
                   signs that the midwife is working in partnership with the person (some narrative by her)
                   any info about what are the needs expressed (not expectations)
                   some trace of discussions and reflections with colleagues
                   more than clinical information_ we accompany a person during a life transformation and transition…. reducing
                  this to clinical info is coherent with a medical approach but certainly not with midwifery. The record is such an
                  important opportunity to illustrate midwifery specificity and philosophy.
                   info on life context, life significant events before and during pregnancy
                   info about family’s client (siblings, parents, children… etc)
                   infos about the number of midwives and other healthcare practitioners involved in the maternity process
                  (continuity of carer)
                   not putting this as optional for practices but as a standard for midwives’ records
                   infos about the newborn…. preoccupations of parents, some aspects of family life etc important for him
                  later…. more than measures
                   infos about client’s decisions about different aspects of her care and not only midwife’s recommendations…
                  something about clients perspectives
                   any difference between consent and choice/decisions?
                   if info about consent and refusal, what about the decision of the woman/person? should be clearer in the
                  record….
                   if the record is for the promotion of informed choice, why only mentioning the risk aspect around informed
                  choice?… is this the only thing discussed?… any trace about different issues, client’s perspective, values and
                  interests?
                   how to conciliate using a language understandable by the woman and the fact that the record could be used
                  by other health practitioners and even by lawers?
                   the record belongs to whom?

                  Why writing “a member”?…. do you have members who are not midwives?…. if not, I would prefer to read: “a midwife”

                  • Thanks for accepting my feedback. For clarity:

                    The reference to “outside of midwifery care” is confusing.

                    I think a main reason why it is confusing is the fact that it is mentioned 3 times. The draft includes:
                    “4. The midwifery record must include a summary of any prenatal, intrapartum, postpartum, or newborn care provided to the client outside of the midwifery practice group.”
                    “9. Documentation of the clinical encounter must be accurate and include:
                    … g. important communication with other care providers, family members, and substitute decision-makers
                    … l. a summary of the care provided by a consultant and any tests or treatments relevant to the client’s care”

                    When I read each independently, they seem clear but being in 3 separate places is what throws me. Consider these edits:
                    Add at the end of #4: “during the current pregnancy and/or postpartum period.”
                    Edit g so it does not address consults/interprofessional care and becomes: “important communication with family members and substitute decision-makers”
                    Put the relevant content taken out of G into L: “a summary of the care provided by a consultant including any tests or treatments relevant to the client’s care and any communication with other care providers.”

                    • No comments or concerns.

                      • Appears complete. I appreciate the stress of identifying clearly who the primary midwife is during these times when shared care is common. I also like the reminder that checklists must be initialed and dated to be valid. All good practice!

                        • The consultation process for the CMO Record Keeping Standard is timely, as CMA is also reviewing their standards for final approval.
                          We appreciated all of the comments thus far.
                          Although our standards are set up slightly differently, many of the comments and the content of the CMO Standards was a great double check to make sure that we had the concepts included as well. Very good idea to clearly identify who the custodian of the midwifery record is. Also liked the note about other providers and their contributions to the record, both as consultants as well as when such reports were received for chronologic purposes.
                          Also appreciated the note re: signature/audit trail and the designation of the author (eg. student, etc).
                          Thank You for this opportunity

                          • After point j. – the non-compliant / unco-oprative client must be documented- what actions the Midwife took to – to establish safety for both Mother & baby.
                            ( eg. Wants homebirth with oligohydramnios, Wants unattended homebirth. Declines post- date follow up.)
                            Document, notify hospital, practice, may call ambulance, CMO, on call OB etc.

                            • Number 4 of the Standard requires clarification:
                              I am not often in receipt of “summaries of care” that have been provided at tertiary centers in my area. It’s a chronic problem, but we are not on the same electronic database system in our Level 2 so we are consistently sending requests for records. We often rely on the client’s report of the care provided to be honest. Midwives are still considered an afterthought I’m afraid. Is a note designating the “summary” as provided by the client enough to satisfy this Standard?

                              Also Number 9 bullet l. Same problem. For example, I had a woman transferred from the local OB to the tertiary center with twins for discordant growth. The only updates I received about her care were from her. She delivered there and when discharged we resumed postpartum care for her and the twins. I had no updates about the birth from the tertiary centre and received copies of the documentation of the details about the neonates from the mother.

                              • Each midwifery record must include the client’s relevant identifiers such as name, date of birth, OHIP number and their contact information (i.e., telephone number and address). Not all clients have OHIP numbers. Why specifically include this in the description rather than indicating that a minimum number of identifiers are required to be able to correctly identify the client referenced in the chart?

                                The midwifery record must include a summary of any prenatal, intrapartum, postpartum, or newborn care provided to the client outside of the midwifery practice group. The meaning of this requirement is unclear. Do you mean if a client has gone for a consult with a specialist, we need to reiterate the assessments/recommendations/outcomes of that consult beyond having the consult letter included in the chart? I think it’s relevant to include a reference to care provided outside of the MPG and to keep an updated care plan but why require a summary of the actual care provided if that care has been documented in the space in which it happened? Is that not a duplication of documentation?

                                Documentation should be chronological and completed at the time, or as soon as possible after an event. When a contemporaneous record of the care cannot be made, a late entry must be documented as soon as possible including the date and approximate time the care was provided and the date and time of the late entry note. Does this mean documentation of the direct care provided by the midwife? Because there will be documentation in the chart that may be out of sequence. Records received from other providers don’t necessarily arrive chronologically but need to be included as part of the record. Doesn’t it make more sense to require that care provided by the midwife should be documented chronologically where appropriate (ie. in an emergency providing direct care is more appropriate than documenting).

                                Documentation of the clinical encounter must be accurate and include…. this list doesn’t indicate the elements must be documented WHERE appropriate. It requires that ALL of the items must be documented every time. But for example, not every encounter requires procedures or treatments, not every encounter includes orders or tests, not every encounter includes discharge from care or transfer. The grammar in the opening sentence needs to reflect that these things should be documented WHEN they occur.

                                • Consider adding a note on confidentiality and secure storage at clinic and when taking client records for transport (i.e.) home visit.
                                  Check #6 for wording…”Be legible” and “written in”

                                  • Looks good!

                                    • The idea of not having complete antenals because it’s else where in the chart makes it’s difficult when there’s a consultation or transfer of care

                                      • Are the proposed requirements clear?

                                        – No, lacks sufficient information.

                                        Are risks of harm to the public addressed? For example, does the standard have sufficient detail that a complete picture of the client’s care is documented?

                                        – No, risks of harm to the public are not sufficiently addressed

                                        1. Confidentiality is not addressed or commented on at all.

                                        2. Retention is incorrect, “ For obstetrical care, the CMPA recommends that maternal records (e.g. prenatal and labour and delivery records) also be maintained for at least 10 years from the time the infant reaches or would have reached the age of majority.” Wording as is, is unclear of intention college is proposing

                                        3. Late entries should include “Late Entry” or other identifier with rationale when necessary, that it is a late entry other than the date and time it is being recorded.

                                        4. Managing erroneous entries is not commented on (for example incorrect details added) errors should be crossed out with a single line in handwritten records for transparency, if another clients identifying details are added, those should be redacted, and note “error” by the entry.

                                        Is the standard achievable for all midwives?

                                        – No, open to too much interpretation. Does not standardize how documentation should be provided. Too much room for even more poor documentation.

                                        Is there anything missing?

                                        – Yes, comment on discouraging subjective entries should be included, such as “lovely primip attended…”, “beautiful baby born at…”

                                        Documentation is objective only, and when it isn’t, opens midwives up to scrutiny should they be called to testify or investigated in legal forums.

                                        • Record keeping is an intergral part of nursing,midwifery and specialist community public health nursing practice. It is a tool of professional practice and one that should help the care process. It is not separate from this process and it not an optional extra to be fitted in if circumstances allow. Moreover, it is high standard of clinical care, it is also continuity of care. Better communication and dissemination of information between members of inter-professional health care team.. An accurate account of treatment and care planning and delivery.

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