Hand Held Records
Hand Held Records are portable, transferable, interoperable personal health records where the master copy is kept by the recipient of health services. The most successful hand-held personal health records are still (2012) paper-based. Getting it right on paper first is the crucial first stage in developing a core flow-patterned personal health record dataset (metadata) that different health record systems will be able to use.
do you agree with the above? let's discuss paper versus electronic hand held records via the discussion tab HJPerry 14:36, 16 April 2012 (BST)
- Perinatal Paperwork for examples of paper records kept by the healthcare provider
- Handover for documentation of handover and transfers
- Red Book for the various manifestations in the UK of the Personal Child Health Record
- Other Hand Held Records for examples of hand held records in other specialties (on the wisdam.info website)
- Perinatal Datasets for links to datasets and information relating principally to electronic health records in perinatal care.
- Original EEPD volume 11 - Casenotes
Policies, procedures & guidance
- Royal College of Physicians (2013) Standards for the clinical structure and content of patient records
- Nursing and Midwifery Council (2009) Record Keeping: Guidance for Nurses and Midwives - due for review 2012 (and still not published as of June 2013)
- UNITE The Union (2012) Record Keeping Guidelines
- Northern Ireland Practice and Education Council for Nurses and Midwives (2012) Standards for record keeping practice for nursing and midwifery Version 6 11th December 2012 Final Draft for Consultation
The following policy, procedure and guidance documents provide an insight into how NHS Trusts work with maternity records, with particular emphasis on hand-held records. N.B. please check with the individual Trusts for the current version of anything listed here.
|Maternity Health Records Policy||2013||Jan 2015||Worcestershire Acute Hospitals NHS Trust|
|The Management of Maternity Health Records||2012||Nov 2015||Royal Cornwall Hospital NHS Trust|
|Maternity Clinical Records Management: Maternity Guideline||2012||July 2015||Imperial College Healthcare NHS Trust|
|Obstetric Hand Held Records||2012||July 2013||Salisbury NHS Foundation Trust|
|Maternity Records||2011||April 2014||East Cheshire NHS Trust|
|Maternity Services Health Records Policy||2010||Newcastle upon Tyne Hospitals NHS Foundation Trust|
|Maternity Records and Note keeping - Management||2009||Oct 2011||East Kent Hospitals NHS Trust|
|Clinical Records Policy||2009||Doncaster & Bassetlaw Hospitals NHS Foundation Trust|
|Record Management Policy & Procedures (V5.1) - see Appendix I: Record Management in Maternity (page 75)||2009||Newham University Hospital NHS Trust|
|Maternity Hand Held Records Procedure (V2.00)||2007||University Hospital South Manchester NHS Trust|
|Health Record Policy & Procedures (TP-74)||2006||Lancashire Teaching Hospitals NHS Trust|
Perinatal Hand Held Records
- Recently completed research on hand held records at Dundee, Bournemouth and Aberdeen Universities, funded by the Chief Scientist Office, Scottish Government, Edinburgh: How is Patient-Centered Care Affected by Giving Women the Opportunity to Write in Hand Held Healthcare Notes? A Qualitative Investigation. MREC no. 09/S0801/85 ; UKCRN ID 8819.
|Antenatal handheld record: complete data set of antenatal items that may be recorded in a hand-held record||NHS Connecting for Health|
|Pregnancy Notes||Perinatal Institute|
|Scottish Woman-Held Maternity Record (SWHMR) version 6||2011||Healthcare Improvement Scotland|
|All Wales Maternity Record Cofnod Mamolaeth Cymru Gyfan||NHS Wales|
|Northern Ireland Regional Maternity Hand Held Record Operational Guidance||2012||Public Health Agency for Northern Ireland|
|Maternity Record||2010||Guy's & St Thomas' NHS Foundation Trust|
|Maternity Notes||2010||St George's Hospital|
|Maternity Care Record (alternative link)||2009||Sheffield Teaching Hospitals NHS Foundation Trust|
|"Co-Op Card"||1970s||this example was issued to pregnant women in Bolton, Lancashire|
- Morley, CJ et al Baby Check: a scoring system to grade the severity of acute systemic illness in babies under 6 months old.Arch Dis Child. 1991 January; 66(1): 100–105.
Personal Child Health Record (Red Book)
see our dedicated Red Book section
Adoption and Fostering
- The British Association of Adoption and Fostering (BAAF) publishes a carer-held child health record booklet (2008) to complement the Personal Child Health Record (Red Book), available for purchase from BAAF.
Go to International Hand Held Records for links to hand held perinatal records from countries outside the United Kingdom.
Many self-help groups, baby product manufacturers, healthcare organisations offer free birth plan resources. These generate much discussion in online message boards, blogs etc. There is wide variation in detail and quality.
|Online birth plan creator||Antenatal Online|
|June 2012 Birth Club birth plan templates||BabyCentre|
|Your Birth Plan||2008||Boots|
|Printable birth plan||The Bump|
|My Birth Plan||HIPP Organic|
|Template Birth Plan for Hospital Birth||NCT|
|Online Birth Plan||NHS Choices|
|Birth Plans – Writing A Birth Plan And A Free Birth Plan Template||AUSTRALIA: BellyBelly (author: Kelly Winder)|
|Birth Plan Template||AUSTRALIA: The Bub Hub|
|Birth Plan template||CANADA: Niagara Health System|
|Birth Plan Worksheet||USA: BabyCenter US|
|How to write a smart birth plan plus birthing plan template tips - blog post provoking heated discussion.||2010||USA: Babble.com (author: Nicolas Greenwood)|
|Birth Plan Creator||USA: Justmommies.com|
|Free Birth Plan||USA: Earth Mama Angel Baby|
|Birth plan creator: easy interactive checklist (ignore the spam comments posted on this blog page)||USA: SheKnows: Pregnancy & Childbirth|
|Since you asked: Birth Plan Template||2013||USA: Shining Light Prenatal Education (author: Deena Blumenfeld)|
|How to create a free birthing plan||USA: SoYouWanna (author: Linda St Cyr)|
Examples of Other Hand Held Records, by Specialty/Client Group
Whereas in maternity care the hand held record is the master record, in most other specialties the hand held record supplements or even only summarises the main patient record. See examples of hand-held records in other specialties on the wisdam.info website