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. 

CHAT theory also explicitly addresses five areas which if addressed systematically will help overcome stakeholder differences in pursuit of the common goal:

1. Understanding the artefacts that characterise the group and its activity.
• The artefacts might be clinical settings or the forms and templates used to capture and share information. During the pilot we heard about hard copy Dialog response forms; locally generated templates for collating information from different systems; letters and emails to GPs; images, poems or other non-text artefacts that service users might want to include in their ‘about me’ or care plan.

2. Understanding the multi-views of the group. Such groups are always a community of multiple points of view, traditions and interests. 
• Different participants in the group will have different roles and will bring to the group and their roles their own histories, language, and ‘rules’. During our Stocktake preparations and workshops we worked with psychiatrists, mental health nurses, occupational therapists, social workers, transformation leads and voluntary sector representatives, all professions and interests with their own language, approaches professional ‘rules’ but united in their interest in care plans, care planning.

3. Activity systems (like the ICSs) take shape and get transformed over periods of time. ‘Historicity’ is a term coined to express how the group’s problems and potentials can only be understood against their own history. 

 

• ‘We’ve always done it this way’, ‘that didn’t work before’, ‘it’s always like this’, ‘it wasn’t always like this’, ‘they are changing things again’, are all typical statements that often frustrate those charged with overseeing change initiatives. Without addressing the experiences that lie behind such comments you risk repeating mistakes of the past, alienating your stakeholders or just not understanding the real starting point for your transformation project. This is particularly the case for the implementation of the PCSP standard, the success of which will be largely reliant on point-of-care practices and information protocols as well as having systems which are user friendly and appropriately configured.

4. The central role of contradictions as sources of change and development. Contradictions are not the same as problems or conflicts. Contradictions are historically accumulating structural tensions within and between activity systems. Collectively addressing contradictions in how policy, practice, culture and technology interact will empower teams to find genuinely novel solutions for apparently intractable challenges, like interoperability and shared care plan/planning. 

This links to the fifth principle that:

5. the possibility of expansive transformations in activity systems. As the contradictions of an activity system are aggravated, some individual participants begin to question and deviate from its established norms. In some cases, this escalates into collaborative envisioning and a deliberate collective change effort. “An expansive transformation is accomplished when the object and motive of the activity are re-conceptualised to embrace a radically wider horizon of possibilities than in the previous mode of the activity.”