News, Secondary Care

Going digital: Midwives get electronic record keeping guidance from RCM

Midwives are finally having their digital moment. There has been a welcome wave of digital developments for maternity services and professionals recently, with the latest including electronic record keeping guidance published by the Royal College of Midwives (RCM).

In the last two weeks alone, HTN has also reported on RCM’s call for a Digital Midwife across every maternity service in the next 12 months, followed by the advertisement of a new job role for a national digital midwife with NHSX. There was also news of a digital maternity triage system, developed in the West Midlands, being made available nationwide.

With all of this transformation afoot, RCM was keen to stress in a statement last week that its members should have the required support to transition to more digital ways of working. Key to that would be training in electronic record keeping, according to the trade union.

“Right now, we are in a hybrid world somewhere between digital and written records, juggling between both for different aspects of our work. That will change and the move to full digital recording is inevitable, and indeed desirable,” said Hermione Jackson, the RCM’s Digital Midwifery Advisor.

After adding that “the NHS, particularly in maternity services, has been lagging behind in the use of digital technology,” Jackson went on to explain that things are “changing” and that it’s “important that midwives and MSWs keep abreast of developments and use best practice when using digital technology for record keeping.”

The new RCM guidance is intended to help with just that. Although, Jackson highlighted, the fundamental rules of good record keeping still apply. “Recording information digitally doesn’t mean recording different information, it’s just a different way of doing it,” she explained, “there will be new things to learn and new ways of doing things but using the technology will ultimately make our working lives easier.”

It’s also hoped that going digital will streamline data collection at both local and national level, and ultimately deliver safer care and better experiences for women during pregnancy and beyond.

“It’s a win, win for midwives, MSWs and women,” Jackson concluded.

The full guidance report published by the RCM, entitled ‘Electronic Record Keeping Guidance and Audit Tool’, is an 11-page online resource that, according to the trade union’s official site, ‘sets out key principles for record keeping, to use in combination with the NMC (Nursing & Midwifery Council) code and local record keeping guidelines’.

The guide itself allows that the ‘full electronic recording of all aspects of maternity care is relatively new’ but that it ‘supports the unique multifunction of maternity records’ and that midwives must ‘adapt their practice to make full use’.

Setting out a ‘best practice summary’ and ‘record keeping governance’, the RCM’s suggestions include highlighting key points. These include that:

  • Midwives and MSWs must receive appropriate training for the electronic record system used in their organisation. Each midwife or MSW is responsible for ensuring this is maintained and updated as required when the system is updated or changed.
  • Midwives should ensure they are up to date with their Information Governance (IG) training and are aware of how to use the electronic record to support IG.
  • Midwives and MSWs should audit their own records regularly in keeping with local guidance and be aware of data which is collected from the electronic system to ensure they support this collection.
  • Midwives should be familiar with local business continuity procedures in case of faults, cyber-attacks, or downtime.

The advisory literature also includes aspects such as staff responsibility for documentation made under their login, a need for clarity when inputting data on behalf of colleagues, as well as the awareness of documentation being available to patients through care records.

Finally, the guide also covers a section of ‘principles for a good audit tool’, including scoring tools and a notes template.

View RCM’s full electronic record keeping guidance online.