The South Australian Pregnancy Record MR31
provides clinicians with the ability to record
information about the pregnant woman such as personal history,
investigations, growth chart, pregnancy illnesses, management advice and
information and birth plan.
The record is created and issued either by the patient’s
General Practitioner or other care provider; for example, the hospital clinic or
midwife at the time of her first antenatal visit following confirmation of
pregnancy.
It is recommended that the hospital and other care
providers maintain their own records of the antenatal visits in addition to
the woman's Pregnancy Record.
Upon delivery the South Australian Pregnancy Record MR31 is
to be filed in the woman’s medical record created by the hospital where she
delivers. A photocopy of the record should also be offered to the woman.
At the time of the first antenatal visit, as much information as possible should be
recorded in the Record.
In some instances it may be appropriate for the woman to
complete some of this information for efficiency as well as a means to
determine her literacy level. In these cases it is recommended that
the woman only
complete page 14, as a clinician would assist the woman to
complete page 15.
Maintenance of hospital/care
provider record
The South Australian Pregnancy Record MR 31 is to be considered
the woman’s main record and the hospital/care provider record as the
supplementary record. The hospital/care provider record should be used for
significant notes that may need to be duplicated or recorded separately, for
example, clinically significant information such as infectious status and
information of a sensitive nature such as previous termination of pregnancies.
Information recorded in the hospital/care providers record must be sufficient
to provide adequate information upon which to base diagnostic and treatment
decisions. It is anticipated that there would not be significant duplication
of information between the Pregnancy Record and the hospital/care
provider record if the pregnancy progresses as expected in the majority of
cases.
It is recommended that all relevant test results are filed
in the hospital/care provider record and if possible a copy provided to the
woman for filing in the orange vinyl cover containing the SAPR.
Clinicians should use an asterisk in the SAPR to indicate
there is sensitive information that the woman does not want documented in the
SAPR (such as TOP). In such cases, the clinicians will know to ask the woman
what the asterisk indicates. Sensitive information should also be documented
in the hospital or shared care notes.
If the woman forgets the Record
If the woman forgets to bring the SAPR to the antenatal clinic it is recommended that she or her
partner/friend/relative return home to retrieve it. If this is not possible or
the record has been lost, notes should be made in the hospital/care provider record and
then the SAPR should be updated on the next visit.
If the woman loses the Record
If the SAPR is lost, the woman should be issued with another record
and the information completed as required.
The SAPR should then be marked "2nd
copy" and the date recorded when it was created. It is recognised that some
information may be lost as a result of re-creating the record.
If the woman transfers to another
hospital/provider within South Australia
If, for example the woman moves from Adelaide to a country
region the Hospital/Care Provider may keep copies of the
SAPR and the woman
may take the original SAPR with her. Where the woman moves interstate
to deliver her baby, the original record should be kept by the Hospital or
Care Provider who was providing the antenatal care and a copy should be given
to the woman.
On admission for delivery
On admission for delivery, the SAPR should be filed in the women’s medical record created at the
hospital where she delivers. If the woman is admitted and has not brought
the SAPR then arrangements for retrieving it should be made.
If the woman is admitted to hospital A to deliver, but is
transferred due to complications and delivers at hospital B, the SAPR should
go with the woman and be filed in her medical record at hospital B. Following
delivery if the woman is transferred from hospital B back to hospital A,
hospital B will retain the original copy of the record.
At discharge
At discharge provide a photocopy of the SAPR should be
provided to the woman
if requested. The information on the front cover of the
record should be completed to indicate that a photocopy has been provided to
the woman. The original record must be filed in the woman’s medical
record at the hospital where she delivered her baby(s). This is a record
management legal requirement. Complete the information on the front cover of
the record to indicate that a photocopy has been provided to the woman.
A copy of the SAPR should also be provided to the primary
care giver (obstetrician, general practitioner or midwife) by giving the woman
an additional copy for the primary care giver, or when the primary care giver
requests a copy at a later date.
Additional information
