Revised – Record Keeping Standard
January 9, 2023
The College’s Record Keeping Standard was revised at the December 2022 Council meeting. The new standard comes into effect on April 1, 2023.
The midwifery record serves as a factual account of the client’s care and is a key form of communication between midwives and between midwives and other healthcare providers. The midwifery record provides evidence to support the quality of the care and clinical decision-making, facilitates continuity of care and reflects the client’s values and preferences. To support this the midwifery record must identify what care was provided and why, who provided the care, when the care was provided and recommended follow-up. In telling the story of a client’s care, the midwifery record must be chronological, legible, and accurate. Clients have the right to records that are complete and understandable. Those records must remain private and secure.
The purpose of this standard is to set out the College’s requirements for documentation in, and management of, records related to the practice of midwifery.
General revisions to the standard
- the format was revised to add distinct sections (e.g., standards for the midwifery record and standards for documentation) and the standards were numbered for easier reference
- the standards were made achievable for both electronic medical records and paper records (e.g., student signatures in electronic medical records)
- the title has changed from Record Keeping Standard for Midwives to Record Keeping Standard to stay consistent with the titles of other College’s standards about specific elements of care (e.g., Prescribing and Administering Standard, Professional Responsibilities While Supervising Students)
What has been removed from the standard
- the “Guideline on Records” section has been removed as it does not set a minimum standard
- the details about specific records (i.e., the Ontario Antenatal Record) have been removed to address the potential for outdated requirements
- standards about client confidentiality and access to records have been removed as these are held elsewhere (i.e., the Personal Health Information and Privacy Act (PHIPA))
What has been added to the standard
- a preamble was added to clearly articulate the importance of record keeping for midwives
- definitions were added that distinguish between midwifery and hospital records
- a standard was added to address issues raised during the consultation about the requirements for documenting erroneous and missing entries
- a standard was added about documenting delegated acts
- the requirement was added that each midwifery practice group’s documentation policy set out how care provided under supervision is addressed
- practice owners are identified as the information custodians responsible for record management
- a standard was added about documenting in an emergency
- a standard was added to ensure documentation is legible and written in either French or English