Читать книгу Examination of the Newborn - Группа авторов - Страница 46

The location of the examination is crucial to the quality of the history‐taking discussion with the mother or both parents. The postnatal ward is not a benign environment as the majority are bustling and noisy and not conducive to a history interview. Women may not disclose sensitive information in this environment for fear of being overheard by other patients and health care workers. Disclosure of domestic violence within the high‐impact family relationship can be prohibited due to lack of privacy. Indeed, the presence of the father or other family members may also prevent disclosures of abuse. Patient confidentiality is paramount within the health service. Equally, noise is a distracting feature for both the examiner and the mother. The maternity services of the future may need to revise the existing provision for the examination of the newborn to accommodate an environment that provides privacy and quietness.

Electronic as well as written documentation should acknowledge and reflect that a detailed history has been taken. The use of a history proforma to record the pertinent history themes and significant risk factors can be used. The history proforma can then be placed in the newborn's medical records as evidence of the history‐taking process along with the documentation from the S4N IT system.