Perinatal Services BC (PSBC) has the provincial mandate to develop a suite of standardized perinatal forms that are used by most health care providers in British Columbia (BC). These forms support best practice in perinatal care and act as clinical documentation tools. It is also within PSBC’s mandate to collect and analyze perinatal data in an effort to evaluate provincial perinatal health outcomes and improve the health system. To meet this objective, specific fields on the perinatal forms are collected as part of a comprehensive database for the British Columbia Perinatal Data Registry (BCPDR).
The forms have been updated to ensure that it is evidence-based and aligned with current clinical guidelines, standards, and best practices. A number of Society of Obstetricians and Gynaecologists of Canada (SOGC) guidelines informed the revisions, along with other national, provincial and local policies and standards, and / or expert opinion from a variety of health care providers, including midwives, physicians, and nurses. Other changes in the forms are intended to improve the format and flow, in an effort to make the forms more user-friendly and support complete and accurate clinical documentation.
The updated BC Antenatal Record
(Form No. PSBC 1905) replaces the 2011 version of the record (PSBC 1582). It was updated to document pregnancy care throughout the antenatal period, and its completion should start at the first antenatal visit, with additional documentation occurring at all subsequent antenatal visits. Form PSBC 1905A
is available as a separate form when additional space is required for Section 17: Prenatal Visit Documentation. At 20 weeks gestation, a copy of the Antenatal Record should be provided to the pregnant individual and to the hospital, and at 36 weeks gestation, an additional copy of the Antenatal Record should be sent to the intended delivery hospital or referral hospital for home births. Once documentation of the antenatal period is complete, the Antenatal Record should be photocopied and added to the pregnant individual’s medical chart, the newborn’s chart, with a third copy to remain with the physician/midwife.
The updated Perinatal Triage and Assessment Record
(PSBC 1910, revised January 2020) replaces the 2018 version of the record (PSBC 1590). It has been updated for the documentation of any hospital visits during pregnancy, including during the antepartum period and hospital admission for labour and delivery. If the pregnant individual presents to the hospital at any point during their pregnancy, documentation should include whether they are admitted to the hospital, transferred elsewhere, or discharged home. Additionally, this form should be completed at hospital intake when the pregnant individual goes into labour, prior to admission to the labour and delivery unit. The BC Triage and Assessment Record does not need to be completed for home births. Information related to the labour and birth episode of care is supplemented by other standard perinatal forms, including the Labour and Birth Record and the Labour Partogram.
The updated Labour and Birth Summary Record
(PSBC 1920, revised January 2020) replaces the 2008 version of the record (PSBC 1588). It was developed for documenting the labour and birth episode of care. In the case of a hospital birth, the completion of the form may begin upon the patient’s admission for delivery, continued throughout the episode of care, and finalized following birth. For home births the form should be completed throughout the episode of care and finalized after birth. Once documenting of the labour and birth episode of care is complete, one copy of the form (the white sheet) should be added to the mother’s chart, the second copy (the yellow sheet) should be added to the newborn’s chart, and the third copy (the pink sheet) should be taken by the health care provider.
We thank everyone who provided feedback over the course of the updated record’s redevelopment.
If you have any questions or feedback regarding the 2020 Antenatal Record (PSBC 1905), Perinatal Triage & Assessment Record (PSBC 1910), and Labour & Birth Summary Record (PSBC 1920), and/or the accompanying materials, please contact firstname.lastname@example.org