Peer Review and Chart Review Standards

Peer review and chart review standards

  • Each region will hold regular peer review sessions at least twice a year.
  • Regular Peer Review recommendations:
    • Each midwife will report:
      • Total number of births since last peer review
      • Total number of cases with absolute risk factors (and where reviewed if not reviewed in current review)
      • Total number of cases with non-absolute risk factors
    • Each midwife will prepare for peer review by:
      • Bringing the chart or a copy
      • Preparing an outline incl. timeline, key lab results, relevant health hx, etc
    • Reviewers will be prepared to:
      • Maintain confidentiality
      • Listen with empathy to the midwife’s experience
      • Give feedback on charting and midwifery care
  • A more structured Chart Review is the standard in the following situations:
    • Maternal hospitalization for infection
    • Maternal hospitalization requiring blood transfusion
    • Uterine Rupture
    • Maternal or Neonatal Death
    • Neonate admitted to NICU within 72 hours(except for observation or anomaly)
    • Transports deemed emergent by Midwife
    • Midwife self requests
    • Suggestion or complaint from community or another midwife
  • Chart Review Guidelines:
    • Review occurs within 3 months of the incident
    • Review is scheduled for about 2 hours
    • Review is done with at least 2 midwives who:
      • Are not part of the midwife’s primary practice
      • Have attended at least 100 births as primary
    • The Midwife provides a full, de-identified copy of the chart for each reviewing midwife
    • The review includes:
      • Thorough chart review (see OMC chart review checklist)
      • Midwife telling her story
      • Questions, comments and feedback from reviewers
    • All copies of the chart will be returned to Midwife and one copy of written recommendations may be given to the Midwife.
  • The intention of chart review is to:
    • Improve charting
    • Identify oversights/mistakes
    • Identify community standards/getting to know how other midwives do things.
    • Improve midwifery practice

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