SA Pregnancy Record Guidelines
(South Australian Pregnancy Record MR31 - Developed: October 1999. Revised every year from 2010)
Purpose of the record
The SA Pregnancy Record will assist maintaining continuity of care, women’s participation in the care and to promote early and appropriate use of antenatal services, particularly among disadvantaged groups.
When to issue the SA Pregnancy Record
The SA Pregnancy Record should be created and issued by the woman’s care provider; for example, General Practitioner, the hospital clinic or midwife at the time of her first antenatal visit following confirmation of pregnancy.
The woman must be made aware that the SA Pregnancy Record is the only complete medical record maintained for her antenatal care and is part of the birthing hospital’s medical record.
It must be emphasised to the woman that it is her responsibility to retain the SA Pregnancy Record and bring it to all health appointments, especially to each antenatal visit and to the hospital for the birth of her child.
Maintenance of information within the SA Pregnancy Record
The SA Pregnancy Record has been developed to be the substantive and only medical record maintained during a woman’s pregnancy.
Information recorded in the SA Pregnancy Record is to be sufficient to meet the care provider’s duty of care in diagnostic and management decisions. Information is to be recorded by the care provider.
For any antenatal visits, attendance or care provision, clinical documentation must be recorded within the woman’s medical record (i.e. progress note).
Information need not be duplicated
The SA Pregnancy Record provides an opportunity for an inclusive and comprehensive medical record to be maintained during the woman’s pregnancy.
Clinicians can use an asterisk in the SAPR to indicate there is sensitive information that the woman does not want documented in the SAPR. In such cases, the care provider will know to ask the woman what the asterisk indicates. Sensitive information should also be documented in other appropriate notes.
It is recommended that the SA Pregnancy Record be photocopied if duplication is required.Superseded photocopied pages are to be destroyed in accordance with the General Disposal Schedule No.28 Clinical and Client-Related Records of Public Health Units in South Australia, Effective 19 Aug 2014 - June 2025
The SA Pregnancy Record is not to be destroyed under any circumstance.Alterations to information should be made in accordance with the South Australian Medical Record Documentation and Data Capture Standards (August 2000).
Antenatal attendance without the SA Pregnancy Record
If the woman forgets to bring the SA Pregnancy Record to an appointment, it is recommended that she or her partner/relative/friend return home to retrieve it.
If this is not possible, information must be recorded in other appropriate notes and updated in the SA Pregnancy Record as soon as possible.
Loss of the SA Pregnancy Record
If the SA Pregnancy Record is lost, the woman must be provided with another and information completed as required.
The re-issued SA Pregnancy Record must then be marked “Second Copy” and the date of issue recorded. It is recognised that some information may be lost as a result of re-creating the SA Pregnancy Record. However, the woman’s medical record will contain clinical documentation of each antenatal visit, attendance or care provision.
Filing of the SA Pregnancy Record
The SA Pregnancy Record must be filed in the woman’s medical record on admission to hospital.
After the birth of the baby, the SA Pregnancy Record is to be filed in the woman’s medical record created by the hospital where she births. If an A4 folder SAPR format was used, please ensure the SAPR page dividers are removed and disposed of, retaining only the loose leaf pages to be scanned and/or filed in the woman’s medical record.
At time of discharge a photocopy of the SA Pregnancy Record can be made available upon request. Should a copy not be requested following discharge, a copy is then only available through a Freedom of Information request.
On request, a photocopy of the SA Pregnancy Record is to be provided to the woman’s General Practitioner or Obstetrician, by the participating hospital.
Transfer to another care provider/hospital
If the woman transfers to another care provider/hospital, the woman must take the SA Pregnancy Record with her. The original care provider/hospital must keep a photocopy.
If the woman moves interstate to give birth, the original hospital/care provider must keep the SA Pregnancy Record, and provide a photocopy of the SA Pregnancy Record to the woman to show her new care providers.
SA Health Medical Record Advisory Unit
SA Health Distribution Centre
Telephone: (08) 8425 9204
Fax: (08) 8124 4655