Risk management considerations and the pregnancy handheld record

Abstract

Risk management is integral to the provision of contemporary health care. As maternity practices change and with a commitment on women being at the centre of care, one strategy has been for women to retain their records during the antenatal period. This paper explores the return rate of the pregnancy handheld record in a major tertiary facility and discusses the risk management implications when the record is not available upon presentation to the treating practitioner. Four audits were conducted over a 2 year period to determine the return rate of the pregnancy handheld record at time of admission for labour and birth. A total of 1096 records were returned out of a possible 1256 during the study. A 6.6% increase in the return rate was achieved over the 4 audit periods (82-88.5%) with an overall return rate of 85%. Our audit highlights the need for consumers, clinicians and heath care facilities to consider the advantages and disadvantages of the pregnancy handheld record, as well as the medico-legal responsibilities that ultimately fall back on the health facility.