A colleague's documentation does not match what you observed
During handover you receive care of a woman who gave birth 8 hours ago by spontaneous vaginal birth after a 700 mL blood loss. The previous midwife documented 'lochia moderate, fundus firm, observations stable' at the end of her shift. On your first review the woman is pale and dizzy on standing, pulse 108, blood pressure 102/64, and the fundus is boggy with a moderate lochia flow. The woman says she told the previous midwife she felt faint an hour before handover. The previous midwife is a respected senior colleague who is now off shift. The obstetric registrar is on the ward but busy with an emergency.
1. Prioritise your immediate actions and explain the reasoning behind the order you choose.
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Clinical safety comes first. The woman has signs of ongoing bleeding and possible hypovolaemia: pallor, postural dizziness, tachycardia, a boggy uterus, and a moderate lochia flow after a 700 mL loss. Begin with a rapid ABCDE assessment, call for help, and start fundal massage while checking observations. Escalate to the obstetric registrar now rather than waiting for her to become free; a busy registrar can still be interrupted for a deteriorating postnatal woman, and the senior midwife or nurse in charge should also be informed.
Establish intravenous access if within your scope and your unit's policy, take bloods as directed, and prepare for possible fluid resuscitation and uterotonic therapy under the registrar's direction. Weigh pads and quantify the loss rather than relying on the word 'moderate'. Recheck pulse and blood pressure after each intervention and document times.
Only after the woman is stabilised and help is in place do you address the discrepancy in the record. The immediate priority is not to investigate the colleague but to treat the woman. Keep the woman informed, explain what is happening, and avoid criticising a colleague at the bedside. If the woman raises the earlier conversation, acknowledge it and record her account accurately.
2. After the woman is stable, describe how you would manage the documentation discrepancy and the professional reporting obligations.
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Record what you observed and did in your own notes, factually and without speculation: the observations, the fundal findings, the estimated loss, the interventions, and the times. Record the woman's account of feeling faint an hour before handover as her statement, not as a conclusion about the previous midwife. Do not alter or add to the previous midwife's entry; if a correction is needed, follow the local process for addenda, which preserves the original record.
Raise the matter with the previous midwife directly if it is safe and appropriate to do so, giving her the chance to explain. It is possible that observations were taken earlier than the entry suggests or that the woman's comment was not heard. Keep the conversation private and non-accusatory. Inform the midwife in charge or the unit manager so the discrepancy can be reviewed through the proper channel.
Your reporting obligation depends on what you find. A single documentation discrepancy is usually managed locally through incident reporting and review. If there is a pattern of inaccurate records, or if the woman came to harm, escalate through the incident system and the relevant regulatory process. You must not conceal the discrepancy to protect a colleague, and you must not make allegations of dishonesty without evidence. Document your escalation steps and the response.