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Defensive Charting Updates 2025

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Full Name (as you would like to have on your CEU certificate)

Credentials to be printed after your name (ex. CPM, CNM, etc)

Last 4 digits of your SSN Number

1. Name one legal or political risk midwives face today with documentation or licensure, and explain how it might be misunderstood by investigators or staff. Acceptable answers include (must name at least one risk + one misunderstanding):

2. Explain the difference between “informed consent” and “informed decision-making.” Why might the latter offer greater protection for both midwife and client? Acceptable answers include (must address both terms):

3.Choose one type of midwifery credential. Briefly describe how the scope of practice for that credential might be misrepresented or challenged during a transport or investigation.

CNM, CPM, CM, LM, Traditional/Unlicensed Midwife
Example of misunderstood or unrecognized scope
Mislabeling as “unqualified” due to lack of awareness
Over-application of hospital/nursing standards

Acceptable elements (must name credential + risk):

4. After reviewing a sample chart note in the session, what were two specific issues that made it legally risky? How would you improve them?

5. List three strategies for documenting a client’s refusal of care that do not rely solely on a “signed refusal” form.

6. What should a midwife do when a client cuts off communication or threatens legal action following an adverse event?

7. What does “sovereign professionalism” mean to you after this training, and how does it show up in your documentation practices?

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