Maternity Information Standard

Digital Maternity Record Standard

The Digital Maternity Record Standard will help to improve the quality of maternity care records and support better information sharing during pregnancy, birth and post-natal care. 

Health and care professionals, charities, maternity IT system suppliers, representative organisations and people who had used maternity services were invited to help shape the standard through a range of consultation opportunities. The latest release reflects this collaboration.

On this page

Current release

Version: v2.1.2
> Standard model – Json
> Standard model – Excel
> Standard model – PRSB viewer
> Supporting documentation (external link to NHS Standards Directory)

From 01 January 2026, this standard will be owned and managed by NHS England and is made available for reuse or amendment under the Open Government Licence v3.0 (OGL 3.0). A review of the ongoing requirement for this standard will be undertaken by NHS England. Details on this and any update to the standard will be published on the NHS Standards Directory. If you have any questions or feedback relating to this standard, please email: england.standards.assurance@nhs.net.

 

About this standard

The primary goal of the standard is to improve safety and effectiveness in maternity care by making sure health and care records are shareable across different IT systems and healthcare providers. The standard covers antenatal to postnatal care, ensuring its adaptability for future digital updates.

Implementing the standard offers several potential benefits;

  • Improves safety by providing accurate and accessible patient records, reducing errors in care.
  • Improves risk management and information accessibility throughout pregnancy
  • Saves clinical time, reducing duplication of data entry and enabling interoperability among healthcare providers.

Summary table

The standard comprises 52 sections, including 15 new sections to reflect new models of care and current maternity best practices. The information model delineates conformance levels (mandatory, required, and optional) and the cardinality for each data element. The conformance and cardinality have been determined from the viewpoint of the professional completing the record.

Many of the items in the standard are shown as required. This information should be recorded when it is available and relevant. However, these items do not always need to be recorded, as some are only pertinent to specific scenarios.

Name Conformance Description
Person demographics R The person’s details and contact information.
GP practice R Details of the person’s GP practice.
Admission details R Admission details
Alcohol record R Details of a person’s alcohol record
Personal contacts R The details of the individual’s personal contacts.
Discharge details R Discharge details
Clinical risk factors R Relevant clinical risk factors
Allergies and adverse reactions R Allergies and adverse reactions
Assessments R Details of the person’s assessments
Contacts with professionals R The details of the person’s contact with a professional.
Birth and baby details M Group containing birth and baby details
            Birth Outcome M The outcome of the birth
Examination findings R Examination findings
Observations R The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.
Family history R Family history
Vaccinations R Details of vaccinations.
Maternity episode details M Pregnancy episode details
Individual requirements R The individual requirements of the person.
National screening programmes R Details of the person’s participation in national screening programmes.
History R Group containing details of past clinical and social care history
Information and advice given R Information and advice given.
Investigation results R Investigation results
Medications and medical devices R Medications and medical devices
Labour details R Pregnancy outcome delivery and birth
Care and support plan R This records the decisions reached during conversation between the individual and health and care professional about future plans and also records progress.
Plan and requested actions R The details of planned investigations, procedures and treatment, and whether this plan has been agreed with the person or their legitimate representative.
Procedures and therapies R The details of any procedures performed. Includes both psychological and medical therapies and procedures (e.g. cognitive behaviour therapy, hip replacement)
Clinical Summary R Clinical Summary
        Clinical summary R Summary of the encounter. Where possible, very brief. This may include interpretation of findings and results; differential diagnoses, opinion and specific action(s). Planned actions will be recorded under ‘plan’.
        Clinical narrative R A description detailing a person’s reason for attendance, results from the diagnostic and treatment process.
National Screening Programme Results R
Referral details R The details of the referral.
Safeguarding R The safeguarding details of the person.
Risks R Details of any risks related to the person.
Fetal scan report R Group containing data items from a fetal scan report
Past gynaecological history R Group containing details of a person’s past gynaecological history
Past Obstetric history R Group containing details of a person’s past Obstetric history
Perinatal pelvic health R Group containing data concepts relating to perinatal pelvic health
Social context R The social setting in which the person lives, such as their household, occupational history, and lifestyle factors.
Legal information R The legal information relating to the person.
About me R About me
            Professional contacts R The details of the person’s professional contacts.
Additional support plans R Additional support plans
Alerts R Details of alerts.
Diagnoses R Diagnoses
Formulation R Details of the person’s formulation.
Investigations requested R Details of any investigations requested
Newborn examination results R Group containing details of newborn examination results
NIPE examination results R Group containing details of NIPE examination results
Problem list R A summary of the problems that require investigation or treatment.
Smoking record R Details of the person’s smoking record
Treatments and interventions R Treatments and interventions carried out
Contingency plans R These are the things to do and people to contact, should an individual’s health or other circumstances get worse.

Endorsement

This standard has been endorsed by the following organisations:

  • Royal College of Emergency Medicine
  • Royal College of Psychiatrists

 

PRSB define endorsement as the public declaration by legitimate stakeholder organisations that that they support a standard, are aware of its purpose, benefit and development methodology, and will promote and encourage the use of the standard to their members, supported by the PRSB. 

Personalised care and support planning for people with severe mental illness

A review of a sample of current care plans, and the way they have been developed, may be helpful in identifying the priorities for this improvement. The PRSB Implementation Guide provides more detailed explanations about each element of the plan, including advice on how the planning process might be best conducted.
These questions might form a checklist for current plans to be compared with. 

1. Does the plan include an About Me section in which the service user, in their own words, can indicate the information they want to be available about their lives, their values, their interests, and priorities, available for all those who may care for them?
2. Is the approach to developing a care plan patient centred and engaging, allowing plans to be based on patient priorities goals, and aspirations, along with the actions they plan to take and the support that they will receive?
3. Is there space for a “formulation” to be recorded in which the person receiving care and the professionals who provide it, share and record the personal meaning and the origins of the person’s difficulties?
4. Are relevant procedures and therapies recorded?
5. Where relevant, are one or more contingency plans included for anticipatable disruptions, exacerbations, or deterioration, and do they include advice on what to do and points of contact for those called upon to respond?
6. Where relevant are additional supporting plans incorporated, (an example being an “educational and health plan” for someone with a neurodevelopment disorder)
7. Is a version of the plan available to a service user (if they wish to have it) in a form and format that they can understand and find to be of value?
8. How is a version of the plan available to the GP and other key parts of the health and care system?

Work conducted by PRSB and partners recently has looked specifically at the suitability of this approach to the development and documentation of care and support plans for people with Severe Mental Illness. This resulted in an updated version of the standard (v1.4), for use by any service and for any group of service users, but with some modifications to ensure that it meets the needs of this community. The approach to a patient centred process of identifying goals, hopes, and values, and the support needed to achieve them, is fully compatible with and can be conducted using, specific tools in use in mental health, such as DIALOG, DIALOG+, and ReQoL, for example. 

Where analysis indicates the need for improvement in the content and process of personalised care and support planning for patients with Severe Mental Illness, specific improvement projects should be instituted to co-design with service users and their representatives, and the relevant staff groups, new approaches, and documentation that would be of value in delivering improvement. The toolkit includes a range of existing resources that could be used to engage in this improvement work, including signposting to relevant existing approaches informed by patient experience-based design.

Moving to a single holistic plan

A review of a sample of current care plans, and the way they have been developed, may be helpful in identifying the priorities for this improvement. The PRSB Implementation Guide provides A key development, consistent with national policy on support for Personalised Care across all health and care sectors, is the move towards an individual with complex needs having a single, integrated, care plan, rather than a series of plans developed by different parts of the health and social care system in isolation of one another. For a patient with severe mental illness, the related concerns and challenges might form a very prominent part of such an integrated plan; many will also have concurrent health challenges and needs. The intention is that the relevant services work together to plan and wrap support around the patient and their family in an integrated way, rather than as a series of sequential or disconnected encounters in which the service user or their friends and family have to adopt the role of the integrator.

A starting point would be to agree priority groups of service users who may already have more than one care plan because they need care from more than one part of the system of health and social care. This could be initiated by looking at service users registered with some sentinel practices or PCNs. Alternatively, the approach might focus initially on people with defined co-morbidity or risk that entails collaborative care with agencies beyond specialist mental health services.

The focus here is on the process of care planning and agreement on what should be shared, rather than solely on the technology used;

1. What is the process to agree which professional will initiate care planning and act as the “lead point of contact” for the service user?
2. Will initial plans be agreed with the service user in joint consultations or sequentially? Where and how will they be conducted?
3. What will be the process to agree the elements of the plans which should be available to professionals and potential authorised users beyond the immediate care teams, (A&E services, Ambulance Services, Social services, etc.) with the service user’s consent?
4. How will elements of the plan be updated following consultations in a way which is proportionate, to allow contact and progress notes to be maintained by the service conducting the consultation, whilst avoiding unnecessary work for partners in care if there is no significant change to the personalised care and support plan?
5. What are the implications for workload, logistics, and administration arising out of these decisions?

The answers to these questions and others will best be elicited through focused joint working, grounded in real, or at least realistic examples. This will entail process mapping, and co-design with a range of professionals, service users, and families. Resources from the toolkit and outputs from the Simulation element of this project will be valuable. Some organisations would adopt an approach such as a Rapid Process Improvement Workshop, planned over several weeks and conducted over a number of sequential days, to develop prototype ways of working that could be tested in the field.