Quality standard

Quality statement 3: Services – record keeping

Quality statement

Pregnant women have a complete record of the minimum set of antenatal test results in their maternity notes.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.

Structure

a) Evidence of local arrangements to ensure that pregnant women have a complete record of the minimum set of antenatal test results in their maternity notes.

Data source: Local data collection.

b) Evidence of local audit to monitor the completeness and accuracy of antenatal test results in women's maternity notes.

Data source: Local data collection.

Process

Proportion of pregnant women accessing antenatal care who have a complete record of the minimum set of antenatal test results in their maternity notes, appropriate to their stage of pregnancy.

Numerator – the number in the denominator with a complete record of the minimum set of antenatal test results in their maternity notes, appropriate to their stage of pregnancy.

Denominator – the number of pregnant women accessing antenatal care.

Data source: Local data collection.

What the quality statement means for different audiences

Service providers ensure that systems are in place to maintain a complete record of the minimum set of antenatal test results in women's maternity notes.

Healthcare professionals ensure that women have a complete record of the minimum set of antenatal test results in their maternity notes.

Commissioners ensure that they commission services that maintain a complete record of the minimum set of antenatal test results in women's maternity notes.

Pregnant women are given a complete record of the minimum set of their antenatal test results in their maternity notes.

Definitions of terms used in this quality statement

Minimum set of antenatal test results

Table 1 minimum set of tests for routine scheduled antenatal care

Investigation

Timing

Blood pressure

All routine appointments

Urine dipstick test for proteinuria

All routine appointments

Full blood count, blood group and rhesus D status

At booking or first scan if booking appointment was not face to face

Height, weight and body mass index

At booking or first scan if booking appointment was not face to face

Sickle cell and thalassaemia screen

At booking

Hepatitis B virus screen

At booking

HIV screen

At booking

Syphilis screen

At booking

Ultrasound scan to determine gestational age and detect multiple pregnancy

Between 11 weeks 2 days and 14 weeks 1 day

Screen for Down's syndrome, Edward's syndrome and Patau's syndrome

Offer at booking

Ultrasound scan between 11 weeks 2 days and 14 weeks 1 day

Ultrasound screen for fetal anomalies

Offer at booking

Between 18 weeks 0 days and 20 weeks 6 days

Measure of symphysis fundal height

All routine appointments after 24 weeks 0 days

Full blood count, blood group and antibodies

At 28 weeks

Abdominal palpation to identify possible breech presentation

All routine appointments from 36 weeks 0 days

Note that women should be able to make an informed choice about whether to accept or decline each test, and notes should include a record of any tests offered and declined as well as the results of tests accepted.

[NICE's guideline on antenatal care, schedule of antenatal appointments]

Equality and diversity considerations

Maternity notes and the information within them should be accessible to all women, including women who do not speak or read English and those with additional needs such as physical, sensory or learning disabilities.

Women should be able to choose whether to have all the results of their antenatal tests documented in their maternity notes. This may be particularly important when information is sensitive (for example, positive screening results for HIV, hepatitis B virus and syphilis). Where a woman declines to have antenatal test results documented in her maternity notes, the results should instead be recorded within other medical notes. It is therefore appropriate that localities give special consideration to these groups of women within the measures. NICE's guideline on pregnancy and complex social factors has recommendations about how to make antenatal care accessible to pregnant women with complex social needs and how to encourage women to maintain ongoing contact with maternity services.