Chart Review Checklist
This checklist can be a useful tool for self-auditing or for peer review
Oregon Midwifery Council
Chart Review Checklist
| Item | X | Comments |
| Client ID on each page | ||
| Midwifery practice ID on each page | ||
| All entries dated | ||
| Record is legible | ||
| Record is organized | ||
| Allergies to meds prominently displayed | ||
| Rh status prominently displayed | ||
| Review of health history documented | ||
| Informed consent forms signed and in chart | ||
| Informed consent for VBAC, breech, and twin | ||
| Labwork and ultrasound as appropriate | ||
| Medications and supplements documented | ||
| Ongoing risk assessment charted | ||
| Plan of action/treatment consistent with diagnosis | ||
| Return visit or follow-up plan documented | ||
| Problems from previous visits addressed | ||
| Appropriate use and documentation of consultation | ||
| Care within scope of practice/license | ||
| Appropriate referrals for psychosocial or economic issues. | ||
| Presence of each midwife and student documented | ||
| Appropriate fetal surveillance at 41+3 weeks | ||
| FHT assessment (prenatal, labor) | ||
| Vitals assessment (prenatal, labor) | ||
| Apgars (1 and 5 minute) | ||
| Immediate PP newborn assessment | ||
| Immediate PP maternal assessment | ||
| Newborn exam documented | ||
| Newborn eye prophylaxis | ||
| Vitamin K | ||
| Metabolic screening | ||
| Newborn hearing screening | ||
| Appropriate maternal PP care | ||
| Appropriate infant PP care | ||
| Appropriate follow-up or referral for PP conditions | ||
| HIPPA compliant records release |