An investigation on the completeness of maternal records: record keeping practices of midwifery nursing care rendered to women in a district hospital in Namibia
Zwartz, Faith Delmarie
The importance of recording information in women’s records is to support the delivery
of good care, clinical decision-making, communication between healthcare workers
and continuity of care. It is assumed that good record keeping practices display the
quality care rendered; hence the recording of actions by midwives provides evidence
of the care they have rendered. A quantitative descriptive retrospective research was
conducted to explore and describe the completeness of record keeping practices of
the nursing care rendered by midwives during all stages of labour in a maternity ward
of a district hospital in Namibia. Seventy-seven maternity records of women who
delivered through normal vertex delivery from the 1st of January 2018 to the 31st of
December 2018 were reviewed. Data collection was done using a structured checklist
to determine adherence to record keeping legislation on completeness of maternity
records. However, many areas of incompleteness of completeness in record keeping
practices kept by midwives were identified.
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