This document is a summary report of the maternity record standard project. It presents:
- Evidence and consensus based standard headings and content definitions for a maternity record with supporting data models and implementation guidance.
- The methodology adopted to develop the standard headings, content definitions, data models and implementation guidance for a maternity record.
This project seeks to improve care experienced by pregnant women and their babies by developing standards for a digital maternity record to allow clinical information to be recorded, exchanged and accessed consistently across care settings. The aims of this work are:
- to ensure that information about the health of pregnant women and their babies will be easily available on a timely basis to anyone that may need the information (parents, health and care professionals and public health professionals), whenever they need it.
- to enable information to be recorded in a common language and made available to women and health and care professionals.
- to ensure recommendations are practical and fit for purpose by adopting an evidence-based approach and consulting widely with pregnant women and parents, health and care professionals and suppliers of maternity health information systems.
- to enable information to be effectively re-used for secondary purposes, such as research, audit and public health surveillance, without requiring separate data collection exercises.
- to support the delivery of the NHS England’s Maternity Transformation Programme and Better Births agenda.
The project was conducted according to the editorial principles for the development of record standards, developed by the RCP and adopted by the PRSB. The focus was on:
- Identifying what information pregnant women and their healthcare professionals require in a maternity record and what information it would be preferable to have in a coded form.
- Identifying what structured (and coded) information it is feasible to include in a maternity record and how this may change with the implementation of more integrated digital patient record systems. This will help to inform phasing of implementation in trusts.
- Engaging with pregnant women, parents, specialists and relevant professional bodies to ensure that the standard meets their needs, they are engaged and support implementation of a maternity record, based on the standard.