An overview of completeness of maternal records: Documentation of maternal nursing care rendered to women during the four stages of labour in Oshakati intermediate hospital
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Date
2007
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Nursing documentation continues to be criticised by professional, community and regulatory bodies because of incomplete, substandard charting practices. Poor documentation may have adverse consequences for care providers because data collection through auditing could create the impression that care was not provided, that is, the impression that what was not documented was not in fact done for the patient. Documentation of the actions of nurses and midwives provide evidence of the quality of care they have rendered, and anything written or printed is a record or proof of activities carried out. Hence good documentation reflects the quality of care and also provides evidence of the accountability of each health care member
This research was conducted in the maternity department of the Oshakati Intermediate Hospital. The purpose of this study was to describe the completeness of the documentation of nursing care rendered during the four stages of labour at the Oshakati Intermediate Hospital. The study was a quantitative, retrospective audit of the maternal records of women who delivered from January to December 2005. A checklist was developed by the researcher and was then used to collect data. Adherence to policy and guidelines of documentation was determined by auditing the documented entries in the progress notes of maternal records as to whether they were dated, timed, had entry modes, were coherent, legible and were signed by the documenter
It is recommended that the controlling body of nursing and midwifery, the Interim Council of Nursing, should formulate a guideline or manual on the proper documentation of nursing care, which could serve as a practical guideline for nurses/midwives and students in the clinical setting. Currently there are no national Manuals of Documentation or Procedures of Documentation guidelines. Maternity department staff should also attend workshops on ways to improve documentation and the importance of documentation in the quality of maternal nursing care, both nationally and internationally.
Nursing documentation continues to be criticised by professional, community and regulatory bodies because of incomplete, substandard charting practices. Poor documentation may have adverse consequences for care providers because data collection through auditing could create the impression that care was not provided, that is, the impression that what was not documented was not in fact done for the patient. Documentation of the actions of nurses and midwives provide evidence of the quality of care they have rendered, and anything written or printed is a record or proof of activities carried out. Hence good documentation reflects the quality of care and also provides evidence of the accountability of each health care member
This research was conducted in the maternity department of the Oshakati Intermediate Hospital. The purpose of this study was to describe the completeness of the documentation of nursing care rendered during the four stages of labour at the Oshakati Intermediate Hospital. The study was a quantitative, retrospective audit of the maternal records of women who delivered from January to December 2005. A checklist was developed by the researcher and was then used to collect data. Adherence to policy and guidelines of documentation was determined by auditing the documented entries in the progress notes of maternal records as to whether they were dated, timed, had entry modes, were coherent, legible and were signed by the documenter
It is recommended that the controlling body of nursing and midwifery, the Interim Council of Nursing, should formulate a guideline or manual on the proper documentation of nursing care, which could serve as a practical guideline for nurses/midwives and students in the clinical setting. Currently there are no national Manuals of Documentation or Procedures of Documentation guidelines. Maternity department staff should also attend workshops on ways to improve documentation and the importance of documentation in the quality of maternal nursing care, both nationally and internationally.
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Keywords
Maternal health services, Prenatal care, Hospitals, Maternity services, Maternity nursing, Midwifery