Digital Maternity Record Standard
The Digital Maternity Record Standard (DMRS) Release 2 has been updated to reflect improvements being made to maternity and perinatal care in line with the priorities outlined in NHS England’s three year delivery plan for maternity and neonatal services.
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 standard will help to improve the quality of maternity care records and support better information sharing during pregnancy, birth and post-natal care.
Current release
Version: V2.1.2 | |||
|---|---|---|---|
Release date | November 2024 | ||
Next release date | November 2027 | ||
Next release type | Scheduled release | ||
The standard | |
|---|---|
Full standard – PRSB viewer | Publishing soon |
Full standard – Excel |  |
Full standard – Json | Publishing soon |
Supporting documentation | Description/purpose |
|---|---|
 | This document includes general implementation guidance for all PRSB standards and detailed guidance, specific guidance for the Digital Maternity Record Standard can be found in the information model (the standard documentation above). |
 | A full list of SNOMED codes that support the Digital Maternity Record Standard. |
 | Glossary of terms for the Digital Maternity Standard Release 2 |
Business rules | Rules for implementation of the standard. |
 | Describes the purpose, methodolgy and stakeholder engagement for developing the standard, along with the findings and recommendations for further work. |
 | Survey findings and analysis. |
 | Summarises the hazards which could result from implementing the standard. |
 | Details the potential hazards from implementing the standard with their risk rating and mitigation. |
Provenance data | Defines the information on who made a record entry and who carried out the activity, where and when. |
Need implementation support?
- Online support form
- Support@theprsb.org
- 020 4551 5225 (9-5 Mon-Fri, excl. bank holidays)
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.
Scope
- Personalised care and support plan for maternity
- Informed consent tool (including decision support tools with patient information aids)
- Equality & Diversity maternity policy
- Midwifery continuity of carer
- Maternal medicine
- Fetal medicine
- Perinatal pelvic floor health
- Smoking cessation
- MEWS / NEWTT-2
- Postnatal GP
- Perinatal mental health
How it works
The refreshed Digital Maternity Record Standard aims to standardise and define the optimal data structure and format for electronic maternity patient records. It is intended for use by clinicians to capture data while providing direct maternity care. This standard will also facilitate the exchange of information between maternity providers, enhancing the quality and safety of care.
The updated 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. |
Further resources
- Standards explained
PRSB’s guide to standards which sets out the purpose and benefits of using standards and how to support frontline professionals to adopt them.
- IHRIM record correction guidance
Despite vigilance when filing information in records, mistakes can occur. The Institute of Health Records and Information Management has guidance to support professionals in making corrections following errors.
Endorsement
This standard has been endorsed by the following organisations:
- Royal College of Emergency Medicine
- Royal College of Nursing