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A Journal on Forensic Medicine
Minerva Medicolegale 2005 September;125(3):171-8
Obstetrics and clinical documentation
Serafini P., D'Antuono L., Mollo E.M., Iorio M.
From the formal point of view, obstetric documentation or the obstetric file is quite similar to the traditional clinical file or documentation; interesting specific differences, however, emerge in terms of content. Of these special aspects, in our opinion, the most interesting are as follows: the need to document the post-natal course as a whole and the value of continuous care; the need to add information regarding the psycho-social health condition of the assisted mother to the obstetric documentation; the need to use an appropriate descriptive language to report on the clinical course and post-natal care that is shared among the various operators; the need to improve the definition of the data to be recorded, the recording of data and the subsequent phase of statistical processing and communication of the resulting information. The recent document of the National Institute for Clinical Excellence «Routine ante-natal care for healthy pregnant woman» stresses throughout the importance of correct information and clinical documentation of the course of pregnancy, and highlights how important it is for information and planned care to be discussed clearly with the mother and for the clinical documentation of the post-natal course to be always left in her possession. The midwives and the other perinatal operators must be aware of and learn how to take on board and correctly describe the biological events of birth (anatomical, physiological and biochemical) and at the same time the psychological and social events for clinical and epidemiological purposes. A well-prepared obstetric file must be able to integrate the aspects relating to objective information (objective data, results of diagnostic investigations and screening tests, when carried out) and subjective information describing the perceptions of persons in care; the latter, in an obstetric context, take on a strategic value because they help operators to clarify the problems and plan correct care (think of the perception and treatment of pain in labor/childbirth, the perception of active movements of the fetus, the self-diagnosis on the part of mothers at the beginning of labor, the correct dating of the pregnancy, etcŠ). The involvement of the mother and her family in decisions regarding her health is an essential element in an obstetric care plan which not only improves the quality of care, but can also provide a valid contribution to the reduction of the much feared legal medical problems; the obstetric file is the instrument that brings together, sustains and promotes.