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Pregnancy

Midwife not recording information in my notes

3 replies

Twiglet15 · 21/05/2016 15:30

Hi there,

I'm a bit worried as have some medical issues from before pregnancy and my midwife hasn't recorded anything I said at the 25 week appointment, in fact she has written 'no concerns raised' in my notes.

I have a condition which causes fainting along with a whole other raft of symptoms. Told the midwife I'd had a bad few weeks with this and that I'd fainted more than 4 times in week leading up to the appointment as well as that I'm having a lot of pain in my pelvis. This to me seems like concerns! I appreciate there's nothing they can do about my faints so I wasn't expecting treatment or even any advice from her really, but for her to have written that I have no concerns is just bizzare IMO!

Is it passive aggressive to stick a post it over her notes to say what I actually told her? I'm worried that the consultant (who I see next) will think I'm weird for not having mentioned any of this to the midwife and suddenly have concerns at his appointment?!

Any suggestions as to what to do about this would be greatly appreciated!

OP posts:
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PerspicaciaTick · 21/05/2016 15:31

I wouldn't use a post-it note. I'd staple my note as a flap over her's.

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CountessOfStrathearn · 21/05/2016 15:45

Don't do flaps over notes. They can be pulled out and can be missed when photocopying.

I'd just write what you discussed in underneath her notes.

"I raised concerns re: repeated fainting..." etc

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Willberry · 21/05/2016 16:12

Medical notes are a legal document and from the legal perspective if as a medical profesional you don't document something it didn't happen eg she didn't discuss it with you. It maybe that what you told her did not concern her with regards to your pregnancy, though I can understand it concerning you. I would discuss it with her and also tell your consultant that you discussed it with her and she didn't seem concerned. I don't know how it works withvpatient held medical records but if you want to add anything then it should be in black ink, timed, dated, signed and with your name printed under signature, as pp said flaps or post it notes can be lost easily.

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