Quality standard

Quality statement 3: Services – record keeping

Quality statement 3: Services – record keeping

Quality statement

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

Quality measure

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 hand-held maternity notes.

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

Data source: a) and b) 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 hand-held maternity notes, appropriate to their stage of pregnancy.

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

Denominator – the number of pregnant women accessing antenatal care.

Data source: Local data collection. The NICE guideline CG110 baseline assessment tool and the NICE public health guidance 27 audit support, criterion 3.

What the quality statement means for each audience

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

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

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

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

Source guidance

Definitions

The minimum set of tests for routine scheduled antenatal care has been developed from the appointment schedule in appendix D of NICE guideline CG62.

Investigation

Timing

Blood pressure

All routine appointments

Urine test for proteinuria

All routine appointments

Blood group and rhesus D status

At booking

Haemoglobinopathies screen

At booking

Hepatitis B virus screen

At booking

HIV screen

At booking

Rubella susceptibility

At booking

Syphilis screen

At booking

MSU for asymptomatic bacteriuria

At booking

Height, weight and body mass index

At booking

Haemoglobin

At booking and 28 weeks

Red-cell alloantibodies

At booking and 28 weeks

Ultrasound scan to determine gestational age

Between 10 weeks 0 days and 13 weeks 6 days

Down's syndrome screen

Combined test: between 10 weeks 0 days and 14 weeks 1 day.

Serum quadruple test: 14 weeks 2 days to 20 weeks 0 days.

Ultrasound screen for structural anomalies

Between 18 weeks 0 days and 20 weeks 6 days

Measure of symphysis–fundal height

Fetal presentation

All routine appointments from 25 weeks

36 weeks

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.

Equality and diversity considerations

Hand-held 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 hand-held 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 hand-held notes, the results should instead be recorded within other medical notes.