Risk management considerations and the pregnancy handheld record:
An audit of the return rate of the pregnancy handheld record
Article Outline
Summary
Purpose
Risk management is integral to the provision of contemporary health care. As maternity practices change and with a commitment on women being at the centre of care, one strategy has been for women to retain their records during the antenatal period. This paper explores the return rate of the pregnancy handheld record in a major tertiary facility and discusses the risk management implications when the record is not available upon presentation to the treating practitioner.
Procedure
Four audits were conducted over a 2 year period to determine the return rate of the pregnancy handheld record at time of admission for labour and birth. A total of 1096 records were returned out of a possible 1256 during the study.
Findings
A 6.6% increase in the return rate was achieved over the 4 audit periods (82–88.5%) with an overall return rate of 85%.
Principle conclusions
Our audit highlights the need for consumers, clinicians and heath care facilities to consider the advantages and disadvantages of the pregnancy handheld record, as well as the medico-legal responsibilities that ultimately fall back on the health facility.
Keywords: Pregnancy, Handheld record, Antenatal, Women, Risk management
Background
The Pregnancy Handheld Record (PHHR) was introduced into major public maternity facilities in the Southern Zone (Qld Health) (Fig.1) in 2001. The rationale to implement the PHHR was for women to be more informed about their antenatal care by having direct access to their antenatal record during pregnancy.1 In addition to comprehensive clinical care, effective communication is pivotal to women's health outcomes which includes satisfaction, knowledge and understanding, and acceptance of advice or treatment.2
Figure 1.
Map of Southern Zone of Queensland (source: http://www.health.qld.gov.au/). (Centres involved in the women-held PHHR: Mater Mothers Hospital, Ipswich Hospital, Toowoomba Hospital, Logan Hospital, Gold Coast Hospital, Redlands Hospital.)
Communication between maternity care providers is contingent on a woman's complete record of antenatal care, management plans, and results of investigations being available to the maternity practitioner at each consultation. Reported benefits of women holding their own pregnancy records include increased maternal control and satisfaction during pregnancy, and increased availability of antenatal records during hospital attendance.3 The ‘woman-held’ antenatal record also allows women time to absorb information related to their care with their partners.4
The study facility has approximately 7000 births per annum. The hospital has a service agreement with state government to provide public care for about half the total of these births. Women are given a PHHR after having their history taken by a midwife and following their booking in visit with an obstetrician. They are advised to carry the PHHR throughout their pregnancy, and present it at each antenatal visit for the care-provider to complete and then return the PHHR at the time of admission for labour or birth. The National Health and Medical Research Council recommends the practice of women carrying their PHHR to improve continuity of care.5 However, it is the responsibility of the health service to maintain and retain accurate health care records. The potential implications to the organisation of misplaced or unavailable records has resulted in several audits in our workplace to determine the retrieval rate of the PHHR at the time of admission, as no duplicate is kept by our health service. At some health facilities steps are taken by staff members to photocopy the PHHR or part thereof. This process is unreliable in terms of being able to ensure that the record is copied and stored in the clinical record in full.
This paper will report on the findings of audits conducted at a tertiary facility and will discuss risk management concerns that may also be of relevance to other organisations.
Methods
Audits were conducted over 4 time periods within a 2 year time frame: February 2003, May 2003, February 2004 and March 2005. Data with the hospital identification label were collected on the audit sheet by administration staff upon the woman's presentation for admission to Birthing Suite regardless of pregnancy gestation. Staff were asked to indicate if the woman was (a) booked into the hospital, (b) if she presented with her PHHR and (c) if the PHHR was already retained in the hospital medical record. Exclusion criteria included women who received private care or had not received antenatal care, that is: unbooked admissions. Data analysis was conducted using simple percentage statistics.
Results
The first audit conducted in February 2003 found that 82% (n
=68) of women returned their PHHR at the time of admission to hospital. Recommendations after this audit were for the staff in Antenatal Clinic to collect all PHHR at the 36 week visit.
A second audit was performed in May 2003 yielding a 1% improvement, with 83% (n=53) of PHHR returned. Whilst this practice of retaining records at 36 weeks was implemented initially, it was not sustained as it denied women ongoing access to their records. New strategies were implemented subsequent to this audit which included placing a large sticker on the top left side of the PHHR in bold for the record to be brought to each visit at the hospital. Midwives in the antenatal clinic were advised to stress to women the importance of always carrying their PHHR. A prompt was also placed on the telephone record sheet in Birth Suite for staff to remind women to bring their PHHR to hospital.
A follow up audit was conducted in February 2004 to measure any improvements in the retrieval of the PHHR. The audit found 86.6% (n=290) of women had returned their PHHR, an increase of 4.6% over a 12 month period. In order to further improve the retrieval rate of the PHHR, a reminder to bring the PHHR to hospital at the time of admission was added to the information sheet for induction of labour and caesarean section, the patient information book (given at the time of the booking in visit) and to the caesarean section information booklet. Clinicians were also asked to retrieve the PHHR at the time a woman was booked for caesarean section or induction of labour.
A repeat audit was undertaken in March 2005 to assess the impact of placing these reminders on the documents stated. With 88.5% (n=685) of women returning their PHHR, an increase of 1.9% was achieved over the previous 12 months and an overall improvement of 6.6% since the first audit 2 years previously (Table 1).
Table 1. Pregnancy handheld record (PHHR) retrieved at the time of admission to Birth Suites
| Audit time period | Number returned | Percentage (%) | Intervention after audit completed |
|---|---|---|---|
| February–March 2003 (7 days) | 68 (83) | 81.9 | Retained PHHR at 36 week antenatal visit |
| May–June 2003 (7 days) | 53 (64) | 82.8 | Prompt to women printed on PHHR |
| February–March 2004 (29 days) | 290 (335) | 86.6 | Prompt to staff to remind women to bring their PHHR at admission printed on telephone record, induction of labour information sheet, caesarean section information sheet and booklet |
| March–May 2005 (108 days) | 685 (774) | 88.5 | Working party for Southern Zone met in August–October 2005 to revise the content and format of the current PHHR. New revised format of the PHHR is due to be introduced in early 2006 |
Discussion
Woman centred care includes the involvement of the woman as an active participant in her own care which is fundamental in determining whether women are satisfied with the care that they receive.2 The PHHR is considered to be one mechanism to enhance the communication process, and to engage and involve the woman and her partner in her care. This study was initiated due to concerns raised by midwives and obstetricians that they were without information regarding the woman's maternity care with increases in actual and/or potential risks when the PHHR is not returned, misplaced or is lost. Similar concerns have been reported in other studies where hospital staff described that they could not adequately provide pregnancy advice when the woman held her full case notes.6, 7 This matter was further reinforced in the recent report into the review of maternity services in Queensland where health care providers expressed their concerns about the woman holding the only complete record of pregnancy care, and consequently expressed their dissatisfaction of not being able to provide satisfactory care across the continuum.8
The current version of the PHHR is not specifically designed to prompt clinicians to make reference to information that is particularly relevant to the consent process, namely the approach to labour and birth, and risks relevant to both mother and baby. These issues although discussed, are not commonly recorded in any detail in the PHHR nor in the hospital clinical record. The PHHR is considered to be the primary document and forms part of the clinical record that is exclusively used for antenatal consultations. Therefore, where consent-related discussions should be recorded in detail in the progress notes, and because the handheld record by design does not lend itself to detailed information, the recording of this information can be overlooked by clinicians.
Legal analysis concerning care management both antenatally and in labour often follows allegations of negligence being made on the basis of:
In an action in negligence in respect to diagnosis, treatment and/or the giving of information to the patient, the clinical record is the most important defence in the health professional/health facilities case that proper treatment was given and or that the woman or family was properly informed. The clinical risk and responsibility intensifies when the woman does not return the PHHR. This can potentially lead to frustration amongst treating clinicians when they do not have access to comprehensive case notes which enable them to readily make clinical decisions. On the other hand, one randomised controlled trial identified that the hospital itself was responsible for losing equally as many PHHR as the women.4 Other studies have reported similar outcomes.9, 10
When considering the standard of maternity care in terms of what do most (relevant) practitioners consider to be competent professional practicea provided to women, the clinical records (antenatal records, pathology results, intrapartum records including CTG's, partogram and progress notes) and other available relevant material will be subject to examination by appropriately qualified specialist/s (obstetricians and midwives). An incomplete clinical record can impact on a claimant's ability to pursue a claim however more often than not, incomplete retention of clinical information concerning treatment provided, including information provided to the woman, results in the defendant health practitioner and/or facility being disadvantaged as opposed to the claimant being disadvantaged. Poor clinical record taking and keeping severely limits any defence and usually works to a complainant's/claimant's advantage.
In evaluating the prospects of success in a medical malpractice claim, relevant considerations include the claimant's detailed instructions which must be considered in conjunction with the details contained in the clinical record along with appropriate clinical opinion concerning these legal issues relevant to the circumstances. The accuracy, completeness and availability of the PHHR to determine the care provided is crucial in terms to properly analysing medical malpractice claims. As a priority a universally accepted and accessible electronic maternity health record should be developed to overcome multiple sources of documentation and include prompts which outline matters that the practitioner or consumer have discussed.
Women's satisfaction levels have been reported previously and have shown that women feel more in control of their care by holding their PHHR.4 However, the authors of this paper were unable to locate any Australian studies that examined the clinical risks associated with the non return of the PHHR at time of admission for birth. When pertinent information is not readily available, full information is not conveyed to all relevant maternity carers and an adverse or sentinel event can result.
Each health service has an obligation to ensure that clinical information is maintained in a complete form. In circumstances where the approach to clinical care is an issue, incomplete records will ordinarily expose the health service.
Therefore, it is the view of the author (MM) that the advantages of continued use of the PHHR can be summarised as follows:
Other significant factors to consider about the PHHR are that despite that the PHHR is promoting a reasonably thorough approach to documenting antenatal care and recording relevant investigations, it is not currently (even in its revised draft form (2005)) intended to be produced for use in duplicate form. Given that it is intended for the woman to maintain responsibility for the PHHR, and that the antenatal record remain in the possession of the woman, it is important to note:
In circumstances when the PHHR is not available, health care providers have no alternative but to act on the basis of any other clinical information held by the health service, their clinical assessment of the woman, information provided by the woman and any additional information that can be sourced on a priority basis from treating clinicians external to the health service.
Conclusion
Through reviewing the PHHR at time of admission and implementing a series of strategies, we improved the return rates of the PHHR by 6.6% over 2 years, albeit via small audits to achieve an 88.5% return rate. The PHHR provides for potential benefits but also possible disadvantages. As with all interventions associated with maternity care, the advantages and disadvantages for the woman in maintaining her PHHR should be discussed. Whilst the possible risk implications and inconvenience for maternity providers and facilities has been outlined, the true risk to organisations has not been investigated here, or found to be previously reported in Australia.
Therefore, ongoing stakeholder assessments are imperative to assess the significance of clinical risk management issues associated with non return of PHHR to the client medical record. The authors support the interaction and enhanced opportunity for discussion and decision making which can result with the woman maintaining her clinical record during the antenatal period. We strongly encourage health facilities to maintain a duplicate record of the PHHR at all times. Particular emphasis for documenting issues in the PHHR around consent, the content and extent of information shared and provision of clinical care is paramount in defending negligence claims.
Acknowledgement
The authors wish to sincerely thank administration staff of Birthing Suites for their support and assistance with data collection during the audit periods.
References
- . Evaluation of the Southern zone pregnancy hand held record. Southern Zone Management Unit Clinical Services Team; 2004;
- . Improving communication between health professionals and women in maternity care: a structured review. Health Expect. 2002;5:63–83
- . Giving women their own case notes to carry during pregnancy. Cochrane Database of Systematic Reviews. 2004;[Issue 2. Art. No.: CD002856. CD002856.pub2.]
- . The introduction of a woman-held record into a hospital antenatal clinic: the bring your own records study. Aust New Zealand J Obstet Gynecol. 1999;39(1):54–57
- . Options for effective care in childbirth. Canberra: National Health and Medical Research Council; 1996;
- . Sharing antental care: client satisfaction and the use of ‘patient-held record’. Aust New Zealand J Obstet Gynecol. 1996;36(1):11–14
- . Continuum of care and the antenatal record in rural New South Wales. Aust J Rural Health. 2003;11:110–115
- . Rebirthing—report of the review of maternity services in Queensland. Qld Health. 2005;22
- . Should women carry their antenatal records?. Br Med J. 1986;292:603
- . The Newbury maternity care study: a randomised control trial to assess a policy of women holding their own obstetric record. Br J Obstet Gynaecol. 1987;94:612–619
- a Refer to s22 Civil Liability Act 2003.
PII: S1871-5192(06)00065-5
doi:10.1016/j.wombi.2006.07.003
© 2006 Australian College of Midwives. Published by Elsevier Inc. All rights reserved.
