Communication and Documentation
Upon completion of this module, participants will be able to:
Describe the legal, regulatory and professional requirements of midwives as related to documentation and the medical record:
- College of Midwives of British Columbia (CMBC)
- BC Freedom of Information and Protection of Privacy Act (BC-FIPPA).
- Health Professions Act (HPA)
- Medical Services Commission (MSC)
- Midwives Protection Program (MPP)
- Personal Information and Privacy Act (PIPA)
- Limitation Act
Discuss the role of communication in client care outcomes.
Identify effective communication strategies for ensuring client safety.
Describe the role and content of handover tools.
Describe the following documentation tools and their role within medical records:
- The Cumulative Client Profile (CPP)
- S.O.A.P. format progress notes
- Salient positives and negatives
- Checklists, templates & care management flow charts
Identify a variety of midwife-client encounters and document appropriately leaving an intellectual footprint.
Discuss the impact of technology on documentation and incorporate safe standards for maintaining appropriate medical records.