When a Claim Happens, Your Chart Becomes Your Voice

No midwife ever plans to be the subject of a claim. But when it happens, your chart is the most powerful piece of evidence you have; it speaks for you when memories fade and emotions are high.

Most claims are not about bad outcomes alone. They’re about missing documentation: what was discussed, what was observed, what was decided, and why. A well-documented chart can make the difference between a defensible claim and one that’s nearly impossible to explain.

At the JUA, we’ve reviewed many years of closed claim files. The same documentation issues appear again and again. Here are the top five charting errors that show up in claims — and how to avoid them.

1. Missing or Incomplete Informed Consent

Informed consent is one of the most common weaknesses we see in chart reviews. The conversation may have happened, but the record doesn’t show it.

Example:

A midwife recalls discussing Group B Strep screening, but the chart only says “client declined GBS.” There’s no note about what was explained, what the client understood, or why they made their decision. When a claim arises, that lack of detail makes it appear that no counseling occurred.

Another place we often see missing documentation of consent is during labor. Every cervix check, every medication given, every AROM should be charted with the client’s consent.

How to avoid it:

• Document that a discussion took place and summarize the key points.
• Record the client’s reasoning in their own words when possible.
• Use clear language like “Discussed risks and benefits of ___; client declined, understanding ___.”

A refusal without context can look like neglect. A well-documented conversation demonstrates respect for client autonomy and professional diligence.

2. No Documentation of Clinical Judgment (Assessment & Plan)

Another frequent gap is the missing “A” and “P” in the SOAP note. The note lists observations (S and O) but not what the midwife thought or planned.

Example:

Fetal heart tones drop to 100 bpm for twenty seconds. The note ends there — no interpretation, no plan. Did the midwife recognize this as a decel? Was something done about it? Was there a plan to monitor more frequently? The record doesn’t say.

How to avoid it:

• Always include your reasoning, even if the plan is to continue monitoring.
• Use phrases like “Because ___, plan to ___.”
• When documenting abnormal findings, describe your assessment of severity and your next step

If your thought process isn’t written down, it’s invisible to anyone reviewing the chart later. Unfortunately when it comes to legal liability, the old adage is “If you didn’t chart it, you didn’t do it.”

3. Copy-Paste and Template Overload

Electronic charting systems make it easy to copy text forward — but that convenience can backfire.

Example:

A newborn visit chart says “Weight gain WNL” because the midwife used a prefilled template, but the baby was actually 10% below birth weight. The inconsistency undermines the credibility of every other entry.

How to avoid it:

• Personalize each note and delete irrelevant fields.
• Review every line before signing. This is harder when you’re tired, so be extra careful during these times or ask another member of your team to review it before posting.
• Avoid “one-size-fits-all” templates; chart what actually happened.

Templates should serve your thinking, not replace it.

4. Late Entries Without Proper Notation

Busy midwives often finish notes later, but failing to identify a late entry can look deceptive.

Example:

A midwife documents a full birth summary two days after the event, without marking it as a late entry. In a claim, that looks like altered records.

How to avoid it:

• Always label with “Late Entry” and include the actual date/time written.
• Briefly state why it’s late (“completed after client discharged due to time constraints”).
• Never backdate. Addenda are acceptable when transparent.

A note made later is still valid if you make it clear when and why. Check out our post on What to Document After a Birth Complication for more details on how to deal with this particular scenario.

5. Incomplete Incident or Transport Documentation

When things move quickly, such as an urgent transport for fetal distress, it’s easy to lose track of times, names, and details. Unfortunately, these omissions create major credibility problems later when the hospital staff, the family, and the midwife all have different versions of the story.

Example:

The record says “transported to hospital,” but omits the reason for transport, when EMS was called, or what was communicated to the hospital team.

How to avoid it:

• Record a clear timeline of key events, in the moment if at all possible.
• Document who was notified, when, and what was communicated.
• Note vital signs, FHTs, and your assessment leading to transfer.
• Include handoff details and plan for follow-up contact with the family.

Your transport documentation tells the story of your professionalism and continuity of care. Incomplete records can make a calm, timely transfer look chaotic.

Patterns Seen in Claim Reviews

These errors rarely happen alone. Often, a claim file shows several of them, such as missing consent combined with missing assessment and late documentation. When that happens, reviewers start to question the accuracy of the entire record.

By contrast, well-documented care tells a story that makes sense. Even when outcomes are poor, clear charting shows sound judgment, communication, and professionalism — and that makes a claim much more defensible.

Quick Charting Checklist for Risk Reduction

✅ Fully document all consent and refusal discussions.
✅ Include your assessment and plan for every abnormal finding.
✅ Avoid copy-paste or blind template use; review every note.
✅ Use proper “Late Entry” notation.
✅ Record all communications, timelines, and transfers in detail.

Your Chart is Your Shield

Charting isn’t just paperwork — it’s part of the care you provide. Each entry is a snapshot of your professionalism, your critical thinking, and your respect for your clients.

Take a few minutes this week to review one recent chart. Ask yourself: Does this note clearly show what I saw, what I thought, and what I did?

That habit alone can strengthen your legal protection more than any insurance policy ever could.

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💬 Call for Comments:
What charting habit has saved you from confusion or complaint? Share your experience below. Your insight could help another midwife stay protected.

The information provided through this activity is for educational purposes only. This information is intended to provide general guidelines for risk management and those involved in claim process. It is not intended and should not be construed as legal or medical advice.