What documentation is a midwife required to maintain for each client?

Midwives are required to maintain comprehensive and accurate clinical records for each client to ensure effective communication, continuity of care, and legal compliance. These records serve multiple crucial purposes: they provide detailed information about the client's health status, progress through pregnancy, labor, and the postnatal period, and document any interventions or decisions made during care. Accurate documentation helps to ensure that any healthcare provider involved in the client's care can quickly gain access to vital information, thus enhancing patient safety and quality of care.

Furthermore, maintaining such records is a fundamental part of professional accountability and ethical practice within midwifery. The Health Practitioners Competence Assurance Act and guidelines from various midwifery councils emphasize the importance of thorough documentation in safeguarding both the client and the midwife.

In contrast, minimal notes or informal communications do not provide sufficient detail or accountability necessary for quality care, and drafts of potential care plans would lack the definitive, verified information needed for effective healthcare practices.