Scoring Tool for Documentation Audit: Midwifery out-patient antenatal care
Record keeping is an essential part of midwifery practice and is vital to support safe and effective care. All midwives should already be familiar with the NMC guidance on record keeping within the NMC Code.
Complete the audit tool to ensure your record keeping standards are up to date. You can email the completed audit tool and reflections to yourself at the end of the audit. Midwives may wish to use this audit tool to support their reflections on documentation as part of their NMC revalidation.
You will need some patient notes you have recently documented in to hand to complete the audit. This version of the audit tool is focused on the midwifery documentation in community antenatal care.