Midwife Licensure Exam Midwifery Pharmacology & Newborn Procedures — Midwifery Documentation, Birth Registration & FHSIS ReportingConcept Map

Related concepts

Concept connections

• Clinical Documentation Records→Birth Registration and Civil RegistryThe delivery record and COLB data come from the clinical records kept by the midwife; they are the source of information for the birth certificate
• Birth Registration and Civil Registry→FHSIS - Field Health Services Information SystemData on births, fetal deaths, and maternal deaths recorded in the clinical chart flow into FHSIS reporting as output indicators and vital statistics
• Documentation Principles and Standards→Clinical Documentation RecordsAll clinical records must be maintained according to universal documentation standards (accuracy, timeliness, legibility, signature, correction protocol, confidentiality)
• Documentation Principles and Standards→FHSIS - Field Health Services Information SystemAccuracy and completeness at the source (ITR and TCL) determine the reliability of all FHSIS output data, monthly reports, and coverage indicators
• Medico-Legal Aspects of Documentation→Clinical Documentation RecordsRecords are legal evidence; informed consent, refusals, and referral documentation are required for legal protection and continuity of care
• Medico-Legal Aspects of Documentation→Documentation in the Context of RA 7392RA 7392 establishes the legal framework under which documentation becomes a professional duty; falsification or neglect of records is a ground for PRC sanction
• What the Midwife Reports Through FHSIS→FHSIS - Field Health Services Information SystemThe specific maternal, newborn, child, FP, and morbidity indicators are the content of what flows through the ITR, TCL, and monthly/quarterly/annual reports
• Documentation in the Context of RA 7392→Medico-Legal Aspects of DocumentationRA 7392 defines the scope of midwifery (normal care and recognition/referral of complications); documentation must reflect this scope and demonstrate competent practice
• Home-Based Mother's Record (HBMR)→Clinical Documentation RecordsThe HBMR is the public-facing card kept by the mother, updated by the midwife; it summarizes key data from the clinical records maintained at the facility
• Partograph (intrapartum record)→Delivery RecordThe partograph tracks labor progress; at delivery, key findings from the partograph (time of delivery, fetal heart rate, maternal condition) are documented in the delivery record
• Certificate of Live Birth (COLB)→Local Civil Registrar (LCR)The COLB is prepared by the midwife and filed at the LCR of the place of birth; the LCR then transmits it to the PSA
• Target Client List (TCL) - by Program→Maternal-Care IndicatorsThe Prenatal TCL and Postpartum TCL are the registers that track pregnant women and postpartum women, respectively, and are the source of numerators for maternal-care coverage rates
• Target Client List (TCL) - by Program→Newborn and Child IndicatorsThe Under-1/EPI TCL, FP TCL, and Sick Child TCL are the registers tracking infants, family-planning clients, and children with illness; they generate the data for newborn and child indicators
• Individual Treatment Record (ITR)→Target Client List (TCL) - by ProgramEach ITR (visit/encounter record) updates the appropriate TCL; the TCL is built from multiple ITRs for a cohort of clients in a program
• Monthly Consolidation Table (MCT)→Quarterly ReportThe MCT consolidates each month's data; the Quarterly Report summarizes the MCTs for all three months of the quarter
• Quarterly Report→Annual ReportThe Quarterly Reports feed into the Annual Report, which provides the yearly summary of program accomplishments, morbidity/mortality, and coverage indicators
• Reporting Cadence and Flow→Demographic and Program DataThe flow from BHS to RHU to Provincial to DOH ensures that demographic data (target populations, facilities, staff) and program output data are consolidated at each level for planning and budgeting
• Corrected Entry→Documentation StandardsThe correction protocol (single line through error, write ERROR, initial and date) is a key standard for maintaining the legal integrity and audit trail of medical records
• Signature with Name and PRC License Number→Documentation StandardsEvery entry must be signed with the midwife's name and PRC license number for accountability and verification of who provided the care
• Confidentiality and Data Privacy Act (RA 10173)→Documentation StandardsRA 10173 protects patient health information; records are confidential and release requires patient consent, a principle integral to documentation standards
• Not Documented, Not Done Principle→Medico-Legal Aspects of DocumentationThis principle means that care not recorded is legally treated as never given; it underscores the legal necessity of documentation and the risk of missing records
• Informed Consent Documentation→Medico-Legal Aspects of DocumentationDocumenting informed consent (and refusals, such as refusal of newborn screening) is a legal requirement protecting both patient autonomy and the midwife's practice
• Referral Forms and Copies→Medico-Legal Aspects of DocumentationA completed referral form with findings and reason, kept as a copy by the midwife, documents that she acted appropriately and referred within her scope
• Record Retention and Ownership→Medico-Legal Aspects of DocumentationThe facility owns the physical record; the patient owns the information; long-term retention ensures records are available for continuity and medico-legal inquiry
• Prompt Reporting of Maternal Deaths→What the Midwife Reports Through FHSISMaternal deaths (and notifiable diseases) are not merely tallied in the monthly report but reported promptly to the RHU/PESU for immediate action and surveillance
• Administrative Sanctions for Poor Record-Keeping→Documentation in the Context of RA 7392The PRC Board of Midwifery may impose sanctions (reprimand, suspension, revocation) for incomplete records or falsification, enforcing the RA 7392 duty
• Scope of Midwifery Practice Documentation→Documentation in the Context of RA 7392RA 7392 defines the midwife's scope as providing normal maternal, newborn, family-planning, and community care and recognizing/referring complications; documentation must reflect this scope

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