Documentation In whatever system is practised good documentation

Documentation

• In whatever system is practised, good documentation is vital. • The midwife should discuss and offer screening tests, record that the discussion has taken place, that the ofter has been made, that the offer has been either accepted or declined.

• It is very helpful for the whole team engaged in antenatal care to understand from the documentation why screening is declined, if this is the case. Women find being persistently re-offered a screening test that they have declined frustrating and annoying

• documenting the discussion properly, rather than ticking a box to indicate that screening was declined, is helpful. This can sometimes also lead on to discussion that can reveal that a woman has not understood the test, the purpose or the benefits, which can help to improve understanding. • -In the event of decline for infectious diseases screening at the antenatal ‘booking’ appointment, a routine re-offer should be made at about 28 weeks.

• Good documentation and being able to show that written information was given can help in the comprehension of such cases.

Discussion of options • When offering tests, it is necessary for the midwife to present and discuss the options, so that women can make an informed choice that best suits their circumstances and preferences. • Midwives are required to discuss options for testing in a manner that enables shared decision -making. • This means providing the opportunity to discuss choices with a trained professional who is impartial and supportive as the women make decisions along the screening and diagnostic pathway.

• There may be mixed feelings about the final decision. Sometimes it is helpful to consider what the mother's worst-case scenario would be, as that can help to decide the best way forward. The principles for consent for shared decisionmaking are shown in Box 11. 1.

Pr inciple s f o r o bt a ining inf o r m e d co nse nt • • Purpose of the procedure/test All risks and benefits to be reasonably expected Details of all possible future treatments Disclosure of all available options (this may include tests that are offered by private providers • The option of refusing any tests • The offer to answer any queries

• -Midwives commonly recommend antenatal tests such as infectious disease screening, full blood count or, cardiotocograph for reduced fetal movements. • - tests for fetal anomaly require a non-directive approach that enables the mother to make an informed choice • -Consent must be obtained prior to all tests and this must be documented. Standardized processes allow good quality of care to be offered to all.

Consent Standards and Guidance for the fetal anomaly screening process which can be used as a model in any healthcare system. • Standard 1: All hospital trusts must have a care pathway to provide evidence information booklet and leaflets are being used. • Standard 2: All pregnant women must be offered, at least 24 hours before decisions are made, up-to-date information on fetal anomaly screening based on the current available

• Standard 3: All eligible pregnant women must be offered ‘testing’ and this offer must be recorded in the woman's notes and/or hospital electronic records at the antenatal ‘booking’ appointment. • Standard 4: All decisions about the test itself must be recorded in the woman's hand- held notes and/or in the hospital records. • It is important all documentation is dated and signed by the health professional involved.

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