Risk management
Charting for Risk Management
An introduction to how accurate, timely, and thorough charting supports safe care and protects against liability.
Clear, accurate, and timely documentation is one of the most important tools a midwife has for providing safe care and reducing liability risk. Whether on paper or in an electronic health record, your chart serves as both a clinical record and a legal document. This page outlines best practices for effective charting, common pitfalls to avoid, and tools to support high-quality documentation. Strengthening your charting habits is a key step in protecting yourself, your clients, and your practice.
Core Principles of Effective Charting
The quality of your charting can be just as important as the care you provide. These core principles support clinical excellence, legal protection, and professional accountability:
Objectivity
Document what you observe, hear, measure, and do, using factual, nonjudgmental language. Avoid assumptions, speculation, or emotionally charged terms. For example, write “client appeared tearful and stated, ‘I’m scared,’” rather than “client was overly emotional.”
Clarity
Write clearly and concisely so that other providers, auditors, or legal professionals can easily understand the record. Use complete sentences when needed, avoid vague abbreviations, and spell out clinical terms unless widely recognized.
Timeliness
Chart as close to the time of care as possible. Delays in documentation can affect accuracy and credibility. If a late entry is necessary, clearly label it with the actual time and date of the entry, along with the time the care occurred.
Completeness
Capture the full picture of care: assessments, findings, clinical decision-making, actions taken, informed choice discussions, and outcomes. Include any refusals of care and the counseling provided. Omissions can create gaps that are difficult to defend later.
Legibility
Whether documenting by hand or electronically, ensure your records are easy to read. Illegible handwriting, inconsistent formatting, or poorly organized notes can undermine the usefulness and credibility of the chart.
Professional Tone
Use respectful, professional language, even in challenging situations. Avoid sarcasm, slang, or language that conveys judgment. The chart is not the place for venting frustrations.
What to Document: Minimum Standards
Every client chart should provide a clear, chronological record of care that includes all clinical encounters, decision points, and communications relevant to safety and informed choice. While midwifery charts may vary in format, the following elements should be documented consistently:
Prenatal Visits
- Date, time, and location of visit
- Vital signs and clinical assessments (e.g., fetal heart tones, fundal height, urine dipstick results)
- Client-reported symptoms or concerns
- Counseling and education provided
- Informed choice discussions and decisions made
- Referrals, labs, or imaging ordered
- Follow-up plans and instructions
Intrapartum Care
- Onset and progress of labor (including timeline and cervical assessments, if performed)
- Maternal and fetal well-being, including vital signs and fetal heart tones
- Clinical assessments and interpretations
- Interventions offered or performed (e.g., position changes, fluids, herbs)
- Communication with consulting or transferring providers
- Informed choice discussions and client decisions
- Time of birth, newborn status, and immediate postpartum care
Postpartum & Newborn Visits
- Maternal vital signs and physical assessment
- Emotional well-being, sleep, feeding, and pain management
- Uterine involution, lochia, perineal status, and lactation support
- Infant assessment and weight
- Newborn feeding, elimination, and behavior
- Review of warning signs and client instructions
- Screening tests offered, accepted, or declined (e.g., newborn metabolic screening, hearing test)
Informed Choice and Refusals
- Content of the discussion, including risks, benefits, and alternatives
- Client questions or concerns
- Client decision and reasoning, if offered
- Signature or verbal acknowledgment when appropriate
- Clear documentation when services are declined, including any counseling provided
Communications and Coordination
- Phone calls, texts, or emails related to clinical care
- Communication with consulting providers, EMS, or other professionals
- Summaries of verbal reports or care coordination discussions
Charting Challenges in Midwifery Practice
Midwives often work in dynamic, unpredictable environments that can make documentation difficult. Understanding common challenges helps you anticipate and manage them without compromising the quality of your charting.
Busy or Emergent Situations
During rapid labors, postpartum hemorrhage, or neonatal resuscitation, the priority is always hands-on care, not charting. However, these high-risk situations are also the most critical to document. Create a system for charting retrospectively with time stamps and clear labeling, and consider assigning a team member to take real-time notes if possible.
Home and Birth Center Environments
Unlike hospital-based care, midwifery practice often occurs in settings without built-in documentation systems. Portable charts, variable lighting, and limited work surfaces can interfere with documentation. Develop charting habits that work well in your setting, such as setting up a consistent space for your chart or using voice memos for later transcription if permitted under your privacy policy.
Team-Based Care
Multiple midwives or assistants may contribute to a single client’s chart over time. Be sure that all entries are clearly signed or initialed, dated, and timed. Use consistent terminology and formats across providers, and establish protocols for handoff documentation when transferring care within your team.
Electronic vs. Paper Charting
Each format has its own strengths and limitations.
- Paper charts offer flexibility but must be legible, secure, and backed up (e.g., scanned) to protect against loss.
- Electronic records can streamline workflows but require careful attention to time stamps, dropdown menu selections, and secure login protocols. Avoid copying and pasting previous entries without review, and make sure your software tracks who made each entry.
Client Access and Legal Scrutiny
Clients have the right to view their medical records, and any documentation may later be reviewed in a legal or disciplinary context. Keep this in mind when recording sensitive information or documenting complex interpersonal dynamics: always remain respectful and professional.
Charting Do’s and Don’ts
Midwifery charts serve as both a clinical communication tool and a legal record. A few key habits can significantly strengthen your documentation, and a few common pitfalls can weaken it. Use this list to keep your notes clear, professional, and defensible.
DO:
Chart in real time, whenever possible:
- If you must chart later, clearly mark it as a late entry with the time of the actual event and the time of the documentation.
Use objective, clinical language:
- Record what you observe, hear, measure, and do — not your interpretation or emotional response.
Document all relevant communications:
- Including phone calls with clients or other providers, text message summaries (if part of clinical care), and informed choice discussions.
Include informed refusals:
- Include details of what was offered, discussed, and declined, and the client’s stated reasons, if any.
Sign, date, and time each entry consistently:
- For paper charts, use full signatures or initials according to your practice policy.
- For electronic charts, ensure secure login and audit trails are in place.
Correct errors properly:
- When charting on paper, draw a single line through the incorrect entry, write “error,” and initial and date the correction. Do not use correction fluid or erase content.
DON’T:
Don’t alter a record after the fact…
- without clearly noting it as a late entry or correction. Post-incident edits can raise serious legal concerns.
Don’t leave blank spaces in paper charts:
- Draw a line through any unused space to prevent future alterations.
Don’t use judgmental or sarcastic language:
- Avoid words like “noncompliant,” “difficult,” or “refused without reason.” Instead, document factual behavior or statements.
Don’t rely on memory for documentation after a significant delay:
- If a note must be reconstructed later, acknowledge that you’re documenting from memory and explain the circumstances.
Don’t chart as someone else:
- Never sign another provider’s name or entry. Use your own EHR login when charting.
Late Entries, Corrections, and Addenda
Even the most diligent midwives sometimes need to make additions or corrections to a chart. When handled correctly, these updates are entirely acceptable, and often necessary. However, improper editing can raise red flags in a legal or regulatory review. This section outlines how to manage late entries, corrections, and addenda with integrity and clarity.
Late Entries
A late entry is documentation that reflects an event which occurred earlier but was not charted at the time.
- Clearly label the entry as “Late Entry.”
- Include the actual date and time of the event, as well as the date and time you are writing the entry.
- Write the entry in the usual format, providing as much objective detail as possible.
Example of a late entry:
Late Entry – Written 6/1/25 at 10:15 a.m. for event on 5/30/25 at approximately 4:00 p.m.: Client called to report increased contractions. Advised hydration and rest. Plan to reassess in 1 hour.
Corrections
When you discover a mistake in your documentation, do not erase, obscure, or delete the original entry.
- For paper charts, draw a single line through the incorrect text, write “error,” and initial and date the correction.
- For electronic charts, use the system’s built-in correction or addendum function. Never overwrite an existing entry.
Incorrect:
“8:30 a.m. – Baby born at 7:45 a.m. 9 lbs 2 oz” (Then scratched out with no explanation)
Corrected:
“8:30 a.m. – Baby born at 7:45 a.m. 9 lbs 2 oz. Correction: Weight was 8 lbs 12 oz, not 9 lbs 2 oz. Correction entered on 6/2/25 by J. Smith, LM.”
Addenda
An addendum is used when you want to add information to a previous entry to clarify or expand on what was already documented.
- Clearly label the entry as “Addendum.”
- Reference the original entry by date/time and explain why you’re adding information.
- Sign, date, and time the addendum just like any other entry.
Example of an Addendum:
Addendum to 5/30/25 6:00 p.m. entry: Forgot to note that client also reported headache with visual disturbances during phone call. Instructed client to monitor symptoms and call if worsening. Written 6/1/25 at 9:45 a.m. – J. Smith, LM.
Charting During or After an Adverse Event
When an unexpected outcome, complication, or emergency arises, your focus is rightfully on providing immediate care. However, thorough and professional charting during or after an adverse event is essential, for both clinical continuity and legal protection. How you document these situations may later be reviewed by regulatory bodies, legal teams, or insurers.
Here’s what to do:
1
During the Event:
- Prioritize care. Charting can wait until the client and newborn are stable. If someone on your team is available, they may record time-stamped observations and interventions as they happen.
- Make brief, factual notes if time allows (e.g., “ROM meconium-stained, FHTs at 90 bpm, initiated position change.”)
2
After the Event: Once the emergency has passed, document as soon as you reasonably can, while details are still fresh.
Include:
- A factual timeline of events (include specific times if known)
- Clinical assessments and decision-making (e.g., why you chose one intervention over another)
- Interventions performed and the client’s response
- All communications, including calls to EMS, physicians, consultants, or hospitals
- Informed choice or consent conversations that occurred in the moment or afterward
- Client emotional responses if relevant (e.g., “Client tearful, expressed fear; explained plan and reassured”)
- Post-event monitoring and follow-up care or referrals
3
Maintain a Professional Tone:
- Avoid defensiveness, blame, or speculation.
- Do not reference your own feelings or self-justification (e.g., “I was nervous,” “I think I did the right thing”).
- Never refer to an incident report, consultation with your attorney, or internal review within the chart.
4
If You Forgot to Chart in the Moment:
- Make a late entry as soon as possible using the correct format (see section above).
- Note the reason for the delay if needed (e.g., “Late entry due to emergency transport and continued postpartum support”).
Templates and Examples
The sample documents, templates, and guidance provided by the Washington JUA are intended for informational and educational purposes only. They do not constitute legal advice, clinical directives, or regulatory requirements. Each midwifery practice is responsible for reviewing and adapting these materials in accordance with current Washington State laws, professional standards, and the specific needs of their practice. The Washington JUA assumes no responsibility for how these resources are used or interpreted.
Templates
Examples
Frequently Asked Questions
What should I do if I forgot to chart something important until the next day?
You can make a late entry — just be sure to clearly label it as such, include the actual date/time the care occurred, and the date/time you’re documenting. Be factual, avoid guessing, and don’t attempt to back-date.
Is it okay to use abbreviations in my charting?
Use only widely accepted medical abbreviations (like “BP” for blood pressure or “FHTs” for fetal heart tones). Avoid creating your own shorthand, as it can lead to confusion or misinterpretation—especially in legal or peer review settings.
Do I need to document informed choice discussions even when the client agrees with my recommendation?
Yes. Informed choice documentation is not just for refusals. Always note that you discussed the risks, benefits, and alternatives, that the client had an opportunity to ask questions, and what decision was made — even when it’s in agreement with your recommendation.
How detailed should I be when documenting emergencies like PPH or neonatal resuscitation?
Be as detailed as possible. Include specific times, assessments, interventions, responses, medications, and communications. If charting retrospectively, document as a late entry and use objective, professional language. Emergency events are the most scrutinized in legal reviews, so clear, factual notes are essential.
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