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.
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.
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
- Please review the proposed Record Keeping Standard (2022)
- Are the proposed requirements clear?
- 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?
- Is the standard achievable for all midwives?
- 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 firstname.lastname@example.org.
This consultation is open until Thursday, August 4, 2022.