Hand Held Records

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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)


See also

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


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.

Document Date Review Date Source
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

UK

  • 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.

Pregnancy Records

Document Date Source
Antenatal handheld record: complete data set of antenatal items that may be recorded in a hand-held record NHS Connecting for Health
Pregnancy Notes

Diabetes in Pregnancy Notes

Planning a Family Diabetes 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

Paediatrics


Personal Child Health Record (Red Book)

see our dedicated Red Book section


Adoption and Fostering
Disabled Children

International

Go to International Hand Held Records for links to hand held perinatal records from countries outside the United Kingdom.

Birth Plans

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.

Document Date Source
Online birth plan creator Antenatal Online
June 2012 Birth Club birth plan templates

Sample birth plans

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



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