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

Concept

Clinical Documentation Records

Sub Concepts

• Home-Based Mother's Record (HBMR)
• Prenatal/Antenatal Record
• Partograph (intrapartum record)
• Delivery Record
• Postpartum and Newborn Records
• Mother-and-Child Book (ECCD card)

Relationship To Central

The core tools the midwife uses to record all maternal and newborn care activities and findings

Concept

Birth Registration and Civil Registry

Sub Concepts

• Certificate of Live Birth (COLB)
• Local Civil Registrar (LCR)
• Philippine Statistics Authority (PSA)
• 30-Day Registration Window
• Delayed/Late Registration
• Certificate of Fetal Death
• Certificate of Death

Relationship To Central

The legal process ensuring every newborn is registered and obtains legal identity

Concept

FHSIS - Field Health Services Information System

Sub Concepts

• Individual Treatment Record (ITR)
• Target Client List (TCL) - by Program
• Monthly Consolidation Table (MCT)
• Quarterly Report
• Annual Report
• Reporting Cadence and Flow
• Demographic and Program Data
• Output Data and Coverage Indicators

Relationship To Central

The DOH reporting system that converts the midwife's daily work into national health data

Concept

Documentation Principles and Standards

Sub Concepts

• Accurate, Factual, Objective Recording
• Completeness and Timeliness
• Legibility and Permanent Ink
• Correction Protocol (single line, error notation)
• No Blank Lines Between Entries
• Signature with Name and PRC License Number
• Confidentiality and Data Privacy Act (RA 10173)
• Not Documented, Not Done Principle

Relationship To Central

Universal rules governing all midwifery record-keeping, tested on the MLE

Concept

Medico-Legal Aspects of Documentation

Sub Concepts

• Records as Legal Evidence
• Informed Consent Documentation
• Refusal Documentation (e.g., newborn screening)
• Referral Forms and Copies
• Record Retention and Ownership
• Electronic Records and Audit Trail
• Protection Against Negligence Claims

Relationship To Central

The legal protection and liability implications of midwifery records

Concept

What the Midwife Reports Through FHSIS

Sub Concepts

• Maternal-Care Indicators
• Newborn and Child Indicators
• Family Planning Indicators
• Morbidity and Mortality Data
• Prompt Reporting of Maternal Deaths
• Notifiable Disease Reporting
• Coverage Rates and Target Populations

Relationship To Central

The specific indicators and data the midwife collects and reports

Concept

Documentation in the Context of RA 7392

Sub Concepts

• Professional Regulation Commission (PRC) Board of Midwifery
• Administrative Sanctions for Poor Record-Keeping
• Falsification of Records as Ground for Sanction
• Scope of Midwifery Practice Documentation
• Competency to Assess and Document Normal Birth

Relationship To Central

The regulatory and professional framework governing midwifery practice and records

To

Birth Registration and Civil Registry

From

Clinical Documentation Records

Strength

strong

Relationship

The delivery record and COLB data come from the clinical records kept by the midwife; they are the source of information for the birth certificate

To

FHSIS - Field Health Services Information System

From

Birth Registration and Civil Registry

Strength

strong

Relationship

Data on births, fetal deaths, and maternal deaths recorded in the clinical chart flow into FHSIS reporting as output indicators and vital statistics

To

Clinical Documentation Records

From

Documentation Principles and Standards

Strength

strong

Relationship

All clinical records must be maintained according to universal documentation standards (accuracy, timeliness, legibility, signature, correction protocol, confidentiality)

To

FHSIS - Field Health Services Information System

From

Documentation Principles and Standards

Strength

strong

Relationship

Accuracy and completeness at the source (ITR and TCL) determine the reliability of all FHSIS output data, monthly reports, and coverage indicators

To

Clinical Documentation Records

From

Medico-Legal Aspects of Documentation

Strength

strong

Relationship

Records are legal evidence; informed consent, refusals, and referral documentation are required for legal protection and continuity of care

To

Documentation in the Context of RA 7392

From

Medico-Legal Aspects of Documentation

Strength

strong

Relationship

RA 7392 establishes the legal framework under which documentation becomes a professional duty; falsification or neglect of records is a ground for PRC sanction

To

FHSIS - Field Health Services Information System

From

What the Midwife Reports Through FHSIS

Strength

strong

Relationship

The specific maternal, newborn, child, FP, and morbidity indicators are the content of what flows through the ITR, TCL, and monthly/quarterly/annual reports

To

Medico-Legal Aspects of Documentation

From

Documentation in the Context of RA 7392

Strength

moderate

Relationship

RA 7392 defines the scope of midwifery (normal care and recognition/referral of complications); documentation must reflect this scope and demonstrate competent practice

To

Clinical Documentation Records

From

Home-Based Mother's Record (HBMR)

Strength

moderate

Relationship

The 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

To

Delivery Record

From

Partograph (intrapartum record)

Strength

moderate

Relationship

The 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

To

Local Civil Registrar (LCR)

From

Certificate of Live Birth (COLB)

Strength

strong

Relationship

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

To

Maternal-Care Indicators

From

Target Client List (TCL) - by Program

Strength

strong

Relationship

The 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

To

Newborn and Child Indicators

From

Target Client List (TCL) - by Program

Strength

strong

Relationship

The 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

To

Target Client List (TCL) - by Program

From

Individual Treatment Record (ITR)

Strength

strong

Relationship

Each ITR (visit/encounter record) updates the appropriate TCL; the TCL is built from multiple ITRs for a cohort of clients in a program

To

Quarterly Report

From

Monthly Consolidation Table (MCT)

Strength

moderate

Relationship

The MCT consolidates each month's data; the Quarterly Report summarizes the MCTs for all three months of the quarter

To

Annual Report

From

Quarterly Report

Strength

moderate

Relationship

The Quarterly Reports feed into the Annual Report, which provides the yearly summary of program accomplishments, morbidity/mortality, and coverage indicators

To

Demographic and Program Data

From

Reporting Cadence and Flow

Strength

moderate

Relationship

The 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

To

Documentation Standards

From

Corrected Entry

Strength

strong

Relationship

The 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

To

Documentation Standards

From

Signature with Name and PRC License Number

Strength

strong

Relationship

Every entry must be signed with the midwife's name and PRC license number for accountability and verification of who provided the care

To

Documentation Standards

From

Confidentiality and Data Privacy Act (RA 10173)

Strength

strong

Relationship

RA 10173 protects patient health information; records are confidential and release requires patient consent, a principle integral to documentation standards

To

Medico-Legal Aspects of Documentation

From

Not Documented, Not Done Principle

Strength

strong

Relationship

This 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

To

Medico-Legal Aspects of Documentation

From

Informed Consent Documentation

Strength

strong

Relationship

Documenting informed consent (and refusals, such as refusal of newborn screening) is a legal requirement protecting both patient autonomy and the midwife's practice

To

Medico-Legal Aspects of Documentation

From

Referral Forms and Copies

Strength

strong

Relationship

A completed referral form with findings and reason, kept as a copy by the midwife, documents that she acted appropriately and referred within her scope

To

Medico-Legal Aspects of Documentation

From

Record Retention and Ownership

Strength

strong

Relationship

The facility owns the physical record; the patient owns the information; long-term retention ensures records are available for continuity and medico-legal inquiry

To

What the Midwife Reports Through FHSIS

From

Prompt Reporting of Maternal Deaths

Strength

strong

Relationship

Maternal deaths (and notifiable diseases) are not merely tallied in the monthly report but reported promptly to the RHU/PESU for immediate action and surveillance

To

Documentation in the Context of RA 7392

From

Administrative Sanctions for Poor Record-Keeping

Strength

strong

Relationship

The PRC Board of Midwifery may impose sanctions (reprimand, suspension, revocation) for incomplete records or falsification, enforcing the RA 7392 duty

To

Documentation in the Context of RA 7392

From

Scope of Midwifery Practice Documentation

Strength

strong

Relationship

RA 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